SDP20,000 Folders -041 1 cqe {i/Form No. 5074/3510

@mrrrq+q .+#qr frqqLIFE INSURANCE CORPORATION OF INDIARd rroga,/Delhi Division -III

ersqqur/Tdr{rd IFq + srefrT qeApplication for Surrender /Discounted Value

qRs €Trcrl qirffr.FThe Sr. Branch Managerqrgfrq #{q *fl furqLIFE INSURANCE GORPORATION OF INDIAslrut $Tqfcrq d./erancn Unit No...................

frq relesZqrrY€r,Dear sir/Madam'

ftsq: qtrrs d............... . Ecft{q .,q....................

ern/Phce.

ffi1-5/Date.

Re.: Policy No. Fvg.s effift crfuff or errqdq iFFil sr6en {r qqqr sTrq{q rF or g.rdrr o-c dr

* t{ sqttffi crffi fui6.........sr!il inrqr q-6ilr El qsqr TS v{r6T grrdF{ or dt

* I intend to surrender my above policy. Kindly pay me the same.* My above mentioned policy will mature on...........................1 intend to have it dicounted value. Kindly

pay me the same.

* d ar.1q d sS ore tr* Delete where lnapplicable

rr{frq / lYours faithfully,

EGilSITSignature

Wr.Trq/ FultName

tl-cTl ,/ Address.

(q-di +o, f+ffiTqr arErn t)(at which cheque is to be posted)

sr1 qrf d q{""""' Eqn q,1 qrfr$

6 sqfifu {fl + g,rdrc 6T sT{Receipt or the Surrender/Disdounted Value of pol icy No.. . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . .on

Rs.

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

frquff ' qR qrffi o.r qrrg*rq d gor d d gs crefTr .rflw srgeFfl d rsren di qrtrqI .

Note : In case the policy is assigned, the application must be signed by the

(vrqi { ga rnq qftd)

FTn d qqtrd 1oq d srfu rfforr ot<r {7o€ t oit*':"""'........-........--.- sc*fi qrfuS rg< ovf tg *er 16r V€ t r *rd gfu d o1.rq qEit w (1er6;

tt75qP artr ETdttrr frd rrnl.

c-qffiH Tfl (qrrfl d TrE 5s vFe)

"'i""".'";"'; ' do hereby acknowledge receipt from Life Insurance Corporatlon of India the sum ofFIc

being the Gross/SurrenderlDiscounted Value including Case Value of Bonus of above mentioned policy which isherewith delivered upto the said corporation to ue cJnceiteo. tn *itness, whereof the presents are subscribed by me/usat

surrender/Discounted Value (inclusive of case Value of Bonus) Rs, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P .

Rs. . . . . . . . . . . . . . . . , . . . . . . . . . . . . . P .D.A.B: Refund

TOTAL Rs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .p .fuq vtfu sTe ff rpff/Less

4t1/Loan

aryu/Loan Interest

fu frqnremium Due

q.fl. \'f,. qr q q[T|/Apl Debit

sria rmrl/x- chargefr{A {rfu/Net Amount payabte soTRs

rro/Rs

so/Rs.....

So,/Rs.

so/Rs..

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"{ d Si,z r,rf scG crftr$ d

rrEr+I C aTqdq ol4t{ +fu qrrftq cftfi Sqr furq + fuff tnrqtffid.Trq iai-ff qrff frt t ** c ggZ* * *sFrS IF S gqcn d qrd srurdq qr XTr?qdq or ot{ *fu sm fu1q d fu€ Frqtdrq d crq "rfl

*drr/qn'-n r A41crrqi qrd, d:

"l / We hereby declare that llWe have not assigned the above Life Insurance Policy to any one nor lAffe have dealtwith the same in any manner, except for any AssignmenVReassignment already registered as on date b.y the Life Insur-ance Corporation of lndia or the Insurer who insured the above policy upon due-Nlotice. lAffe hereby further Declar:e that l/We have not served on any office of the Life Insurance Corporation of India any other or turtnei noil;;i iJgnr"nt o,.reassignment in respect of above policy, nor shall lAtVe serve on any office of the said Corporation any notice of assign-ment or reassignment before payment of Loan/Surrender Value/Survival Benefit',WITNESS:

ERlItrt/SignatureuR ga cm-q 500 s. r)sr f6ddl rn:orr r f tSF6E arrrRi

Flupee One Revenue Stamplo be af f ixed i f GrossSurrendei Value is Rs.500

g il{/FullName.

qEqrq/Occupation.

(ffqted d fwrenr/Signature of Life assured)

SonofAlVifeof2

tltll/Address

cle Eil qfu Te fud c if Er+:rtr *{r q.rm ZGV M Rrtrqd orqldrq d ryr* d qtrd gqrFril ffie Sar'sr ql qfu 3ttF +{f, qr que fr6,sur**4 qr trurcfuil qffi rrr r,girr. aro ffid rrflsq wq frqmq crerErsqw S{tr6,d cEnr€rd/qtrrqruTqar * vrquqq +r; ;= qr frqq d carq ffi 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 amd qrft qrFgl ffi d qFrril Grar qFfr t #reftil eli qq o+ ArO cRso, ffi qmi Ed q* 6 6rgy-sflps q;qqr

"'tR' fI ** qI sFldr frcnq a *ry --a # *ril a n- *v"n if EKt€rr 6rn qrBq,

, .,1' Note :.:Jllitrate persons must afix thumb marks which should be identified by attesting Magistrate under the seal ol r,i, otrt"lby a Justice of the Peace or a Block oevetoprnent o#i.lr-"i"tazetteo officer oia eiincipat/Headmaster of Locat,High.school or Higher secondery Ftgor run uv the Government

"; ;;;;;i; N;";"ti.eo aank or a ctass I officer of rhecorporation or a Deveiopment otficer of th'b cqrporation with at teasifive years service or oy an Agent of the corpoiaiionwho is'a member of the ciub at the level tt oioision"r naanageiand above provided hl/she is fully satisfied about theidenlity of the person (s) 6xecuting the form',signature in negionat Languages ru.io"

"tt"sted by a respectabre English,Knowlng pelson The witne,ss attesting tne signltuies or tnu-rii riarks shoutd sign the Dectaration betow: ,.,,i .,

ss g:rdH .Df ?FT frfiq f.............. .......6.i wqsr fur,rqr d sltr s€H Arqq Al',-ffi- qft'qw *i d qF{ 6 sTqi Fsilrerr fu't t/errfl r*wr a.nqr tr ,. ,' . _ . l . : . . , . . , - ,

6 - ! r ' t . - r q r

The content of this discharge form have been exprained to , '

and helshe/fhey hqs/have signed,the same after understanding the same.

SEAL OF OFFICE

tr Auv ' .,,

gnff or gc ;na/Name of Witness

qrr*/Occupation

tlct/Address

o.rqffiq or getzSeat Office- ,

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lmportant

lf the within written *t"-'ll j:.:9L?9,by more.than one person and payment is desired to be made to onty one of them thenthe following note of authoriti riust ne comfeled and signed by alt ot them before a magistrate or to a Justice of peace orGqzetted officer or a Block-Devetopment'ori."1 or a Frincipal/Headmaster of L6cat Hign_scrroot or Higher secondaryschool run'by the Governmgnt or Agent of a Nationatised Bank "r;;;r;'<iiii#"t

iil" corpor"tion or a Deveropmenrofficer of 'the corporation with at l6ast tru" v""i.-.";"i";;;;;d.d. he/shs i. turrv ,"ti.ti"o about the ident*y of theiff?:l$::.the

letter of Authoritv will also be required it paym5ni i. to n* made to "nv

p"oon other rhan the signatories or

gnfl d Eiilerr/Signature of Witness

Tem/Phce

futo/oate

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

Witness: (See introduction below)

{c +r/Full Name

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

Effiefi/Signature

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

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

@ qI rilRffi ernr'ffq d twtrq

q sqFn o,rrer € fu gs 3TFo.n q? ?FI fratul S/ffi

uq ga,d ffir 1916 qri srd qgr if rrrrcn. Rqrrqr en efq ftn stfuqd

aqfu qt aqRildi oi qoq 6t U,rdrq frtq qri d ftK sdrd i I

I hereby cer t i f y tha t the conten ts o f th is Note o f Author i ty were exp la ined by me in vernacu la r to shr i i

has/have agreed to payment being made to.""""""" """"""" ' the

party or parties authorised

Signature of Witness

$ rgmrzrull Name......'

lnstructions:

gs 3rfumn o-{ d ffi qr qRw enw ffs qr trqqkd srffi rrr ENus fto.rs sTlffi qT ITs.FTt am qiqrfrrc sq

fil-srmq q1 @rtrr qrgqfuo ffqrdrq d cqnrqrd/uur+rwrro q1 q$+qa do d \'*€ qr ftrrq d sQrq e}fr eTfffi ?TI

ftarqSfr6maTffi,d$qeorrqiqs{*-*11-6T6Tdst}<rwreflofri lr itdEItdguierorrig€it dscR'Qrfr

C ewrrc ffi qri qGqt

This letter of authority must be signed before a Magistrate or a Justice of peace or a Gazetted officer or a Principal/

Headmaster of Local High school or Higher Secondary school run by the Government or an Agent of a Nationalised Bank

or a Class I ofiicer of the Corporation or a Development ofiic"r of .the Corporation with at least five years service provided

he/she is fully satisfied about the identity of the executants'

: qfr 3Tffi 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

ett* fts rrr Etus ftuors qfffi qr crschd sTfffi qT sqirT{ am qiqrfuc reTr+q sq ftoraq qI sal qrellfrfi'

ffqrtrq d sq','rd/cqFilrqrc6 q1 qrq15Ed ilo d \rd-€ w ft{rq d qarq *oft 3TfDmTA d oq t oq ctq q{ t-{r€ €

9-6l d erfl lrt.Fr E<TIen f+t qrtrq I

This endorsement is required to be completed and signed by the attesting Magistrate or Justice of the peace or Block

Development officer or Gazetted officer or a principal/Headmaster of Local High School/Higher secondary School run by

the Government or officer of Nationalised Bank or class I officer of the corporation or a Development officer of the

Corporation with at least five year,s service when the note of Authority is executed by an illitrate or vernacular knowing

person (s).