Claim No.
BMSSY/______________
FORM V (A)
See Rule (8.1)
CLAIM FORM FOR ASSISTANTCE UNDER BINA MULYA SAMAJIK SURAKSHA YOJANA
To
The Beneficiary Registering Authority
Bina Mulya Samajik Suraksha Yojana
Gangarampur LWFC,Dakshin Dinajpur
Sir/Madam
I, Sri/Smt. __________________________________________________________________________________
and my SSIN is_______________________________________________________________________________
OR
1. I, Sri/Smt. ___________________________________________________________________________________
Nominee of Late______________________________________________________________________________
Residing at___________________________________________________________________________________
____________________________________________________________________________________________
Do hereby submit my claim for assistance under the scheme as details below:
(Signature of Beneficiary/Nominee)
Claim of benefit of Provident Fund(See Rule 8.1)
Sl No. Details
a. Name of the Beneficiary
b. Registration No. under erstwhile SASPFUW
c. Type of Cliam(Tick the appropriate box) Premature Closer
Final Payment
d. Relationship with decease beneficiary,if
nominee is applicant
e. Date of Death
f. Amount of Claim
g. Name of the Bank and Branch
h. Bank Account No.
i. IFSC
Passbook (Form-II) is to be submitted in Original
The statements made herein above are true and correct to the best of my knowledge and belief.
Date:
Place:_____________________ (Signature of Beneficiary/Nominee)
CERTIFICATE
(If the application is submitted by Nominee)
I know the applicant Sri/Smt.________________________________________ and hereby certify that the statements
made by him/her are true to the best of my knowledge and belief.
Date:
Place:_____________________ Signature with seal of Local Authority
Mentioned under Rule 8.4.3(1). (e)