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The document is a claim application form submitted by Shrivastav Bikeshlal Dinanathlal for a refund of deposits made to the Sahara Credit Cooperative Society Limited. It includes personal details, deposit information, and a declaration affirming the legitimacy of the claims. The applicant acknowledges the consequences of providing false information and agrees to indemnify the society if any discrepancies are found.

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15 views2 pages

Adobe Scan Nov 08, 2023

The document is a claim application form submitted by Shrivastav Bikeshlal Dinanathlal for a refund of deposits made to the Sahara Credit Cooperative Society Limited. It includes personal details, deposit information, and a declaration affirming the legitimacy of the claims. The applicant acknowledges the consequences of providing false information and agrees to indemnify the society if any discrepancies are found.

Uploaded by

shubhamsrivastava7313
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Claim Application Form

ial qtu f/Claim Reguest Date 03-11-2023

fgu HatgaT3te/ Dear Sir/Madam,


À, qa T4ll, Full NameShriyastay Bikeshlal Dinanathlal
fAm/qfa l IH/Father/Husband Name S/O: Dinanathlal

Sign across the


photo
Date of Birth: 09-01-1971, do hereby apply for a claim against my
deposit(s)/ contribution(s) amount which is to be credited to my following Bank -

51 4/Bank Name: AXIS BANK

Following are my deposit details:

Membership Certificate/ Account Deposit/


lClaim/SocietylScheme No.
Account No. Receipt No.
Passbook No. Opening Contribution Deposit oan Loan
No. Code Name
Date Amount PartiallyAmt Repaid
Repaid

1 SCcSL 14-12
14351301571/15354802650l80277323192 351004209036 50000
2013
2 |SCCSL 14-12
|14351301571/14354802651 80277323193|351004209037 2013
25000

3 |SCCSL 02-12
|14351301571|1435480241280293321514|351004209003 2013
25000 0

ylgU/Declaration

ÀShrivastav Bikeshlal Dinanathlal yagI rqu htll f Sahara Credit Cooperative Society Limited, HAf 1

AT à HEi HIEq 3i HTtr/ARRI RI Sahara Credit Cooperative Society Limited. uafa f. y arm

8E2BE340A8873EEFOCFS37728458763A Page No. 1 of 2


Credit
1. Shrivastav Bikeshlal Dinanathlal hereby declare that I am a genuine depositor/member of Sahara
details
Cooperative Society Limited, Society Ltd. and have made legitimate deposits in this Society as per the
Societies
given above in this application form. Ihave given details of all the deposits made by me in the above
in all the Schemes. The aforesaid information given above is true and correct to the best of my knowledge and
belief and | have provided true proof of my deposit and claim. The said deposit(s) were made by me in the
Sahara Credit Cooperative Society Limited. Society Ltd. out of my legitimate income before 22.03.2022 in case

of Sahara Credit Cooperative Society Ltd., Lucknow, Saharayn Universal Multipurpose Society Ltd. Bhopal
and Humara India Credit Cooperative Society Ltd., Kolkata and before 29.03.2023 in case of Stars
Multipurpose Cooperative Society Ltd., Hyderabad and in compliance with relevant Income Tax Laws.

2. If any of the information given by me in the above application form is subsequently proven to be incorrect or
false, Ihereby undertake to return the refunded amount along with the applicable interest to 'Sahara-CRCS
Refund Account' and indemnify the "Sahara CRCS Refund Account' to the said extent. Ishall also not pursue
the claim in other forum to the extent it is settled by the 'Sahara-CRCS Refund Account'.

3. Further, I shall also be liable for any civil or criminal action in accordance with law, in case of any falsehood
or misrepresentation.

Ag/Date: 03-1 1-2023 ZHd0 E1 VATa/Signature of Depositor:.Já,.-dftAA4


HUA/Place:
AThaí h AIA/Name of Depositor:Shrivastay Bikeshlal Dinanathlal
arg R/ Mobile No: 9998305917

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