Claim Application Form
ZIa| HTRy fei#/Claim Request Date: 25 Jun, 2024
fry HgteA/T3te,/ Dear Sir/Madam,
4 qRT IH/L, Full Name: Sarita Devi Agarwal
fM/g 1HH/Father/Husband Name :
yI/Address 1:
YGI/Address
fiel/District : Sign across the photo
f s/Pincode
Iv/State :
Date of Birth : 06-09-1976, do hereby apply for a claim against my
deposit(s)/ contribution(s) amount which is to be credited to my following Bank:
I H/Bank Name: BANK OF INDIA
Followingg are my deposit details:
GKI R.J
Membership Account Deposit/
Claim Society Scheme Name Account No. Receipt No. Certificate/ Contribution Deposit Loan Loan
No. Code
No. Passbook No 0pening| Partially Amt Repaid
Date Amount
Repaid
11211708530 11216716952 444003167486
20-12 18000
1 SCCSL 2017
11-07
2 SUMSLGLOBAL(SMCSL)911218007367 34027786018|337005365666 2018
18000
11-07
3 SUMSLGLOBAL(SUMSL)|911218007367 34027786019 337005365667 2018
15000
ESUT/ Declaration
1 Sarita Devi Agarwal yGGRI Equ rI f Sahara Credit Cooperative Society
Limited, Saharayn Universal Multipurpose Society Limited i VG HTÍNs OÍHCEU str ÀFH
1R d I HEÌ HAu feui I spA IRI/GHRIÍui aRI Sahara Credit Cooperative Society
Limited,Saharayn Universal Multipurpose Society Limited dy r HERI hf&T F030TCA HHISI
TT HIh 22.03.2022
1. Sarita Devi Agarwal hereby declare that Iam a genuine depositor/member of Sahara Credit
Cooperative Society Limited, Saharayn Universal Multipurpose Society Limited_and have made
legitimate deposits in this Society as per the details given above in this application form. I have
given details of all the deposits made by me in the above Societies in all the Schemes. The
aforesaid information given above is true and correct to the best of my knowledge and belief and I
have provided true proof of my deposit and claim. The said deposit(s) were made by me in the
Sahara Credit Cooperative Society Limited, Saharayn Universal Multipurpose Society Limited out
Society Ltd.,
of my legitimate income before 22.03.2022 in case of Sahara Credit Cooperative
India Credit
Lucknow, Saharayn Universal Multipurpose Society Ltd., Bhopal and Humara
Stars Multipurpose
Cooperative Society Ltd., Kolkata and before 29.03.2023 in case of
Incomne Tax Laws.
Cooperative Society Ltd., Hyderabad and in compliance with relevant
application form is subsequently proven to be
2. If any of the information given by me in the above
amount along with the applicable
incorrect or false, I hereby undertake to return the refunded
the 'Sahara CRCS Refund Account' to
interest to 'Sahara-CRCS Refund Account' and indemnify
other forum to the extent it is settled by the
the said extent. I shall also not pursue the claim in
'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.
Ia/Date: 25 Jun, 2024
HAPlace: of Depostor áania Aqeraa
GHIOTÍ I TH/Name of
Igci gR/ Mobile No: Depositor: Sarita Devi
9123227005 Agarwal