-041 SDP20,000 Folders 1

@m
qrgfrq #{q *fl furq
qRs Trcrlqirffr.F The Sr. BranchManager

cqe {i/Form No. 5074/3510

rrrq+q
Rd

LIFE INSURANCE CORPORATION INDIA OF

rroga,/Delhi Division -III

.+#qr frqq

qe ersqqur/Tdr{rd + srefrT IFq

Application for Surrender /Discounted Value

ern/Phce. ffi1-5/Date.

LIFEINSURANCE GORPORATION INDIA OF slrut $Tqfcrq d./erancnUnit No...................

frq relesZqrrYr,
Dear sir/Madam' ftsq: qtrrs d...............
Re.:PolicyNo.

. Ecft{q .,q....................
Fvg.

* *
*

s effift crfuff or errqdqiFFil sr6en qqqr sTrq{qrF or g.rdrr o-c dr {r t{ sqttffi crffi fui6......... sr!il inrqr q-6ilr El qsqr TS v{r6T grrdF{or dt policy. I intend surrender above to my pay Kindly methesame.
My abovementioned policywill matureon...........................1 to have it dicounted intend value.Kindly pay me the same.

*
*

d ar.1qd sS ore tr
Deletewherelnapplicable
EGilSIT

rr{frq / lYours faithfully,

Signature Wr.Trq/FultName
tl-cTl Address. ,/

frquff ' qR qrffi o.rqrrg*rq d gor d d gs crefTr .rfl w srgeFfl d rsren di qrtrqI .

Note : In casethe policyis assigned, application the mustbe signedby the

(q-di+o, f+ffiTqrarErn t)
(at which chequeis to be posted)

sr1qrf d q{""""' 6 sqfifu {fl + g,rdrc6T sT{

Eqn q,1qrfr$

Receipt the Surrender/Disdounted of policyNo............... or Value

.....,..................on

Rs.

qrrff?T grrEETqr cftfi dt*r furq C scE-ffi rTrftr$d q.e 6u ritrc'..

(vrqi { ga rnq qftd)

FTnd qqtrd 1oqd srfu rfforr ot<r {7o t oit*

':"""'........-........--.sc*fi qrfuS rg< ovf tg *er 16rV tt75qP artr ETdttrr frd rrnl. c-qffiH (qrrfl d TrE 5s vFe) Tfl t r *rd gfu d o1.rqqEitw (1er6;

"'i""".'";"';'
FIc

do herebyacknowledge receipt from Life Insurance Corporatlon Indiathe sum of of

beingthe Gross/SurrenderlDiscounted including Value Case Value of Bonusof above mentioned policywhichis herewith delivered upto the said corporationto ue cJnceiteo. *itness, whereofthe presentsare subscribed tn by me/us at

surrender/Discounted (inclusive caseValue Bonus) Value of of

D.A.B:Refund

R s ,. . . . . . . . . . . . . . . . . . . .P... . . . . . . . R s .. . . . . . . . . . . . . . . , . . . .P... . . . . . . . TOTAL Rs..............................p.

fuq vtfu sTe ff rpff/Less

4t1/Loan

rro/Rs so/Rs.....
So,/Rs.

aryu/Loan Interest fu frqnremium Due

q.fl. \'f,. qr qq[T|/Apl Debit sria rmrl/x- charge payabte fr{A {rfu/Net Amount soTRs

so/Rs..

rtlt. \rq am dR-atntrr q/o-rd B fu N sc *Fs si ds6r (ofr urt srr*qfl cTFrSrrff qf,d 6 tidqe tnr fi d Si,z r,rf scG crftr$ d Tt Erd +qr irgqrs anr qrrftq cftfi Sqrfurq + fuff tnrqtffid.Trq "{ qrfffrt t ** c ggZ* * rrEr+I aTqdq C ol4t{ +fu iai-ff * sFrSIF S gqcn d qrd srurdq XTr?qdq ot{ *fu sm fu1qd fu Frqtdrq crq qr or d *drr/qn'-nr A41 crrqi qrd, d: "rfl
"l / We herebydeclarethat llWe havenot assigned aboveLife Insurance the Policyto any one nor lAffehavedealt with the same in any manner,exceptfor any AssignmenVReassignment alreadyregistered on date b.ythe Life Insuras ance Corporation lndiaor the Insurerwho insuredthe abovepolicyupon due-Nlotice. of lAffe herebyfurtherDeclar:e l/ that We have not servedon any officeof the Life Insurance Corporation Indiaany other or turtnei noil;;i iJgnr"nt o,. of reassignment respectof above policy,nor shall lAtVe in serveon any officeof the said Corporation noticeof assignany ment or reassignment beforepaymentof Loan/Surrender Value/Survival Benefit', WITNESS: ERlItrt/Signature g il{/FullName.

uR ga cm-q 500 s. r) srf6ddlrn:orrrftS F6E arrrRi

Flupee Revenue One Stamp lo be affixed if Gross Surrendei Value Rs.500 is

qEqrq/Occupation. tltll/Address

(ffqted d fwrenr/Signature Lifeassured) of

SonofAlVifeof 2

cle Eil qfu Te fud c if Er+:rtr *{r q.rm Rrtrqd orqldrqd ryr* d qtrd gqrFril ZGV M S ffie ar'srql qfu 3ttF +{f, qr que fr6,sur**4 qr trurcfuil qffi rrr r,girr. aro ffid rrflsq wq frqmq crerEr sqw S{tr6,d cEnrrd/qtrrqruTqar vrquqq +r; * ;= qr frqq d carqffi sr* qr Rqq d mrs [Ed' d 6q t oq qiq s{ +qrrd q gol Et $fr* s'd .r{i srd qfu qff qeqn d qR { qor*, qE d d am d qrft qrFgl ffi d qFrril Grar t #reftil eli qq o+ ArO qFfr cRso, ffi qmi Ed q* 6 6rgy-sflps q;qqr

, ' Note:.:Jllitrate persons mustafixthumb marks which should identified attesting be by Magistrate under sealol r,i, otrt"l the by a Justice the Peace a Blockoevetoprnent of or o#i.lr-"i"tazetteo officeroia eiincipat/Headmaster of Locat,High. schoolor Higher secondery run uv the Government ;;;;;i; N;";"ti.eo aankor a ctassI officerof rhe Ftgor corporation a Deveiopment or otficerof th'bcqrporation "; teasifiveyearsservice oy withat or an Agentof the corpoiaiion who is'a member the ciub at the leveltt oioision"r of naanageiand hl/she is fullysatisfiedabout idenlity the person 6xecuting form',signature negionat aboveprovided the of (s) the in Languages ru.io" by a respectabre English, Knowlng pelsonThewitne,ss attesting signltuies tnu-riiriarksshoutd tne or "tt"sted betow: signthe Dectaration ,.,,i ., ss g:rdH .Df ?FT frfiq f.............. .......6.i wqsr fur,rqr d sltr sH Arqq Al', qft'qw qF{ -ffi' . _ . l . :

"'tR' fI

**

qI sFldr frcnq *ry a

--a # *ril a n- *v"n if EKtrr qrBq, 6rn

.,1

*i d

. . ,

6 sTqiFsilrerr t/errfl r*wr a.nqrtr fu't

. . , - , 6 - ! r ' t . - r q r

,.
,

The contentof this discharge form have been exprained to and helshe/fheyhqs/havesigned,thesame after understanding the same. SEAL OF OFFICE

'

tr Auv

' .,,
gnfl d Eiilerr/Signatureof Witness

gnff or gc ;na/Name of Witness qrr*/Occupation

tlct/Address

o.rqffiq or getzSeat Office

fts vr rrvqFd sTRorft zrr Erus fuflq .tfu-ff rrr q-*Fl-{ arn du.rfud rQrrffs v@ uqrarqn-dTsufftrrqarqtvt*qq-odEdqqrqrTrfrrrqdcQrq*l,,ftsTffiqIf*.|.+ffidoqdEqd_s frETdq d E{ qr{'d q 36't d 3fr EF) -qtq d ilt d wt*t qEE +d qqs or vsd ERilefi F{i qrRqr.ffi gg grrfin qt EKIen 6Ti qrd arFn + friff q-q qm a a.n r,or t d vs evn ir ftq sTfu-.n qa w.ru' o1 rff srrqT{fidr Ei'ft1 lmportant

trd w.m 1fi- qffi i *r{ frn t frE g-.rdr{ s ftnft qn Erhq qnffi qri ol qor qm r{c * qfl ry.sT fu T 6) q6qdi o,rsTthrvfu iil d sfr eli * .* Hs qfuir{ifs} fd RqrsTtrnn *6o1e llt qa 3rF4f, q qfu enw'

-,

lf thewithin written *t"-'ll j:.:9L?9,bymore.than person payment desired one and is to be made to thefollowing of authoriti note riust ne comfeledandsigned altot thembefore magistrate ontyoneof themthen by a or to a Justice peace of or Gqzetted officeror a Block-Devetopment'ori."1a Frincipal/Headmaster or of L6catHign_scrroot Higher or secondary schoolrun'bythe Governmgnt Agentof a Nationatised or Bank iil" corpor"tion a Deveropmenr or officer of'the corporation with at l6asttru" v""i.-.";"i";;;;;d.d. "r;;;r;'<iiii#"ti. turrv,"ti.ti"o he/shs aboutthe ident*yof the letter Authoritv alsobe required paym5ni to n* of will it i. made to p"oon other rhanthesignatories or iff?:l$::.the "nv

Tem/Phce

futo/oate

TE qfu qr qRir{ii i frq o1 Eqfufr C affier frtqt

below) Witness:(See introduction {c +r/Full Name

trq) (slfo,rt crq fuq Eg aqfu.?F'l

Effiefi/Signature

F----------ftr arrlFull Name

qil,/Address -------------

qI rilRffi ernr'ffq d twtrq

q sqFn o,rrer fu gs 3TFo.nq? ?FIfratul S/ffi Rqrrqr en efq ftn uq ga,d ffir 1916 qri srd qgr if rrrrcn. aqfu qt aqRildioi qoq 6t U,rdrqfrtq qri d ftK sdrd i I

stfuqd

t by me in vernacular o shrii I h e r e b y c e r t i f y t h a t t h e c o n t e n t s o f t h i s N o t e o f A u t h o r i t yw e r e e x p l a i n e d agreedto paymentbeing made to.""""""" has/have party or partiesauthorised of Signature Witness $ rgmrzrull Name......' lnstructions: """""""'the

am rrr ENus fto.rs sTlffi qTITs.FTt qiqrfrrcsq qr qRw enwffs qr trqqkd srffi gs 3rfumno-{ d ffi qr ftrrq d sQrq eTfffi ?TI q1q$+qa do d \'* e}fr fil-srmqq1@rtrr qrgqfuoffqrdrq d cqnrqrd/uur+rwrro dscR'Qrfr ftarqSfr6maTffi,d$qeorrqiqs{*-*11-6T6Tdst}<rwreflofrilritdEItdguierorrigit C ewrrc ffi qri qGqt
peace or a Gazettedofficer or a Principal/ or This letter of authoritymust be signed before a Magistrate a Justice of Bank or the Government an Agentof a Nationalised school run by of Headmaster LocalHigh school or HigherSecondary with at leastfive yearsserviceprovided of .theCorporation ofiic"r or or a Class I ofiicer of the Corporation a Development he/sheis fully satisfiedabout the identityof the executants' : qfr 3Tffi

qr crschd sTfffi qT sqirT{ am qiqrfuc reTr+q sq ftoraq qI sal qrellfrfi' ett* fts rrr Etus ftuors qfffi d q1 qrq15Ed ilo d \rd- w ft{rq d qarq *oft 3TfDmTA oq t oq ctq q{ t-{r ffqrtrq d sq','rd/cqFilrqrc6 qrtrq I 9-6l d erfl lrt.Fr E<TIenf+t or of or Magistrate Justice the peace Block by and to is Thisendorsementrequired be completed signed the attesting run School by secondary of LocalHighSchool/Higher officeror a principal/Headmaster officeror Gazetted Development officerof the or a Development Bank or the Government officerof Nationalised or class I officerof the corporation knowing or by is whenthe noteof Authority executed an illitrate vernacular service with Corporation at leastfive year,s person (s).

q{ rr{i qrd qfu

sTRIftK t slsrdl f

d 3idr'n {'eq tTI'fl/tTIS t d geio-q rqruFrqR

ffi"

qr irRe*t