Specimen of form to be completed by claimant(s) for payment of

balance of Account of a Deceased Account Holder.

To
The Manager,
Bank of India,
Udaiyur Branch,
B.Udaiyur.
Dear Sir,
Res: Claim for payment of Balance of Account of __________________
I/We furnish the following particulars in connection with the above account and
request to repay the balance of the account of the deceased account holder who expired
on

at Kilavadinatham Village in Bhuvanagiri Tk, Cuddalore District

against an indemnity Bond Death Certificate enclosed.

..2..
____________________________________________________________________
S.No

Name

Age

Sex

Occupation

Relationship
With the deceased

______________________________________________________________________
1.

R.Kalavathy

49

Female

Wife

______________________________________________________________________
1. Deceased
2. Claimants/ Heirs

Thiru

R. Kaliyavaradhan

1. R. Kalavathy
(Proof of Indentify enclosed) for Family Card Xerox, and Votter ID.
3. Two Sureties with Address:
1.

2.
______________________________________________________________________
S.No
Type of A/C
No.
Amount
______________________________________________________________________
SB
CD
RD
TDR
Please enclose pass book /Cheque book/
TDR as applicable.

Total Rs.

_____________________________________________________________________
5.Other Assets & Liabilities of the deceased.
(a) Asset (Movable other than claimed amount. Please include deposits with other
Banks/ branches/receivable etc.,
_____________________________________________________________________
Details

Value

Their claimans.

_____________________________________________________________________
..3..

(b) Immovable Properties

______________________________________________________________________
Details

Value

Their Claimans

______________________________________________________________________

______________________________________________________________________
( c ) Liabilities including tax liability and unsatisfied creditors if any
7. Whether deceased left a will?

Yes/ No

8. Whether any legal representation

obtained like succession certificate etc.,

Yes/ No

9. Any other facts which the applicant ( s) wants to state in support of his / her / their
claim.

Yours faithfully

Specimen of Indemnity Letter Regarding Payment of balance of

Account of a Deceased Account Holder.

From:
R. Kalavathy
Kilavadinatham,
B.Udaiyur (Post)
Bhuvanagiri TK.
To
The Manager
Bank of India
B.Udaiyur Branch.
Dear Sir,
Re: Payment of balance of Rs.................................................. in the account of
Mr. R. Kaliyavarathan.
Mr. R. Kaliyavarathan ( Deceased had the current account No. SB
Account
Account No.

monthly income certificate double benefit deposit

Recuring deposit Account No.

With

your bank.
3. Mr. R. Kaliyavarathan had expired on 8.6.2016 at Kilavadinatham
Bhuvanagiri Tk, leaving at the time of his death the credit balance in
his respective account as under:
a)current Account
b) Savings Bank Account No.
c) Fixee / Short / monthly income
Certificate / Double benefit Deposit
Account No.
d) Recuring deposit Account No.
Total

Rs.
Rs.
Rs.
Rs.
_____________
Rs.
_____________

..2..
3. I / we have represented to you
a) That the deceased died without leaving a will and I / we the undersined.
i)
ii)
iii)
iv)
am / are the only heir (s) of the deceased according to the law of intestate succession
applicable to him /her.
a) That the decades died leaving his/her last will and lestmon
dated ........................................ and
the undersigned Mr. R. Kaliyavarathan are the executors their and that had he
/she died with out leaving the will, we the undersigned namely.
Name of heirs
Whoul have been the heirs of the deceased according to the law of intestate
succession applicable to him / her.
b) That we do not intend to obtain any grant of legal representation to the
estate of the deceased.
c) That the are the only persons entitled to the properties and assets of the
deceased as such executors / heir as on intestany.
4. We have requested you to pay the said balance in the said account (ts)
if all ........................................... of us the undersigned namely.
____________________
Which you have agreed to do the faith and strength of and relying on my / our
above representation and on my / our executing such indemnity inmyour favour as is
hereafter appearing.
5.In consideration of above premiss. I / we so as to bind my self ourselve jointly and
each severally and you have agreed heirs, executors administers estate and severally
undertake and agree with you your successors and assigns as follows:

.3..
a) To keep you sale and indemnified against all claims, demands, actions
proceedings lesses , damages, cost charges and expanse the legal costs
being between attorney and clent which may be made or bought or
commenced against you or be paid sustained suffered or incurred by you
howsoever, as a consequence direct or indirect of your paying the said sum in
the above accounts to me / us without insisting on agar ant of legal
representation.
b) To pay to you ondemand that amount of any such losses danagees, costs,
charges and expenses together with interest at ....................... % P.A from the
date of payment by you until reimbursement by me /us.
Yours faithfully
In consideration of the premises, we the undersigned ......................................................
.............................................................................................................................................
Jointly and severaly guarantee to you, Bank of India, the payment of all money due
under the aforesaid indemnity by me executants thereof.
Signature
1. Name
Occupation
Address........................................................
.....................................................................
.....................................................................
Signature
2. Name
Occupation
Address........................................................
.....................................................................
.....................................................................
Signature