sDP 50.000-12/12 eTrlrs?T i5fteq ctrt ri,/Form No. 5074/351 sqr frrrq 0 LIFE INSURANCE CORPORATION OF INDIA ffi qusa/Delhi Division -lll eicqdq/wrqd loq d meiil qt Apptication for Surrender /Discounted Value qRG6 €Irail gr*I?F The Sr. Branch Manager rrrr&q Eft{q Sqt ntrq LIFE INSURANCE CORPORATION OF INDIA yrsr rrrq|oq ri./B ranch U n it No,.................. frq rTdqq/rr*{ql, Sir/Madam, Dear _o rd........... fttrq: qrFRft :{ rR........-. rgdlqq Re.: Policy No. Fvg. qrffi q,T enqfq $it=rr qr€Hr Rr qrrqr eruftr TRI EFI Urrgrq mt d .6] qR,q{ffi znl srq d {fl t I .rqT C nr6't +ff s.r*w qTtrRft frqi-6. * * ti erq-4 t Er6rqrl Te{r tnq iF'it=TI qrgtrl Rt qqqr f* strol gqdn env t I | intend to surrender my above Policy. Kindly pay me the same ...1 intend to have it dicounted value. Kindly pay me My above mentioned policy will mature on........ * *' the same. * cil en1 q * ' d eri tnrc dI T{r =Trq/ Full qil / : qR qrRnff tnr rfirgtyn S gtrT d q{ Name d 5gr nef+ va rrr{tRff d rwren dli ilRq d.r{....................... qrfl (qsi I 6 rrqf{'d lga d y-61q o,1 .............scn ........:....... Address.. Note : In case the policy is assigned, the application must be signed by the assignee. 61 Yours faithfullY, ff*renrZSi gnatu re.................".'.. Delete where Inapplicable M rr{ftq ,/ d t6 {\s{FTt End* t) (at which cheque is to be Posted) crFi6 {........................ *tq Beceipt or the Surr g€rE arrl qndrq Gftfi 61 ftrs C €lr$-ffi qTRFff d qtn Tfl r{trd (sr<t d Ea roq qRn) -''....'...-.'.---....:....-...-...-...-...'H.#;.q.;-.*'ffi it,zgqri am rr<rers Qri 'ri t surrender/Discounted value (inclusive of case Value of Bonus) D.A.B. Refund TOTAT Rs. frtiT vrft mre aft rr$lless -1P1/Loan qrq/Loan lnterest tq frKZPremium Due q.S. g.?. q qqrril/Apl Debit er;q rtrii /x- charge illw va-E arql $R-c o-csr d,/ore d fr ftrd sc dFs si uf.s6-{ (qfr ih)d d) Gfr qrlfrq d-fi ffql ftqq grerqr qftr$ irr0 o-{i sre Aqr srgqd dm q-6e fl duffefl inr $ .d d {iZ es+ sqEffi crfu{ff + scslw vrer+tii srqdq fl al$+Es qrftq+{i +ql furq+ffi{,rqi-irqSilqcnQ rfi er& t gtt{cf VEq rq $q ffRff 1tu d g'rcrt d wd qaa{q qI Xflq{q 6r ?i{ *eT{ s?f, ft{rq d ffi orqldq d crq qro 6'{ian//6ii t ffi qmi qrd $: "l/ We hereby declare that lA ,le have not assigned the above Life Insurance Policy to any one nor l^^,e have dealtwith the same in any manner, except tor any AssignmenvReassignment already registered as on date by the Life Insurance Corporation of India orthe Insurer who insured the above policy upon due Notice. lrlA/e hereby further Declare that l^/ve have not served on any office ofthe Lile Insurance Corporation of India any other or further notice ofassignment or reassignment in respect of above policy, nor shall l/vve serve on any office of the said Corporation any notice of assignment or reassignment betore payment of Loan/Su rrender Value/Su rvival Benefit" qR WITNESS: E-c{ ro-q 500 in'. 3Trffid*1n.mrsfi-fr Fd'e lgl ilt{/Full ffnil Rupee One Revenue Stamp to be alfixed if Gross SurrenderValue is Rs.500 (fiqrq! d Wsrqn/Signature of Life assured) Son of/Wife of NEFT MANDATE FORM a (t I AccountType: Savings/ CurrenU Cash CrediVNRl O Account No. (Bank account number should be written from left to right) MICR No. IPS Code: Mobile Number: + l9 r Emailid t 1 : iiliqfuyefuid rri w-* oqql drn-{ qtRs ffi Rrcrqd olqltrq d *t-g d r{trd }rqrFrd qffie.e Sdrtlqr !ilfus 3ffq ft{t rn su's ft-6r{r 3{D-6Rii rn v-oqFs orfffi qr r-r,F.rr ETs ii"rkd errfiq.a*;';; J m qYRT S curnrqd/qqntqrqo qr vsrrq-d +cF S qI Farq S celq shff 3Tfuqr{ qr frqq d ft-6r{ \'+€ eifM, cfr oq fr oq qis s{ +{..f, iE_g6r e|*{ *'r{ rri u'A reer< ; *t S Ei# *g* d d am d wS 1Fr dqr{i erRs r ffi d irdrqr s|-q,{IqI { ERrerffi r}i qq s€ ffi cRs6 ard qfu d am cqrn-d o-rfl qGc r i-i H Ewnan ar oiSor Rvm ol sqrFr. 6-{i qre rrres of frq q}qsn { rwren o-gi qrRq; cte: Note: llliterate persons must atfix thumb marks ivhich should be identilied by attesting Magistrate underthe sealof his office by a Justice of the Peace or a Block Development officer or a Gazetted ofticer or a principal/Headmaster of Local High School or Higher Secondary School run by the Government or an agent of Nattnatised ulnk oi a class I officer of the corporation or a qftigor of the corporalion with at least five y6ars service or by an Agent of rhe corporation who is a member ot rhe uluo aI rne level ol Divisional Manager and above provided he/sho is lully satisfieJ about the identity of the person (s) executing the form Signature in Regional Languages must be attested by a respectabte English Knowing person. The witness aitesting the srgnalures orthumb marks should sign the Declaration bslow: P::"!?,i:" gd{ 3?TSn q:I t} srqi E-ffiqfi fut fr{ilvr S............ d/orq.+r ei.pr .ryqm t <trl ...........rrr rrrfl frqr.Rn t sin s€ii firfiq qi .rS qiR qrrs di d qrE I The content of this discharge form have been explained to .....,...... ..'...and he/she/they hasihave signed the same after understanding the same. SEAL OF OFFICE IF ANY rneft qil Hrt ;rFI/Name of Witness............ rndfr S frcren/Signature of Witness orqnrq oI 3fl ,/Seal Off ice vRgs gr-fl-qqiqr\E ri 3IE-6qfu{fi ieeren ffi€ fu-€g.r-drigrq * fu,ff\'dFqfuol ffriqridE:€'r +aaff iit ft-q qfu o} ror *l 61 3Tfqqrn i:cr E} s0 dg o-{ €rq rr$ qfrilqj *1fld Rqr i[fi-o.n q-, qGil*e ql qfus 'T{ i silo'*q qr t|dqBf, srffi sI rso.s f6Ts srlffi-fff ql TI[6R am riqrfuc errffq va h.gr6rq S cElr|rqrd/strFFarq-fi qI {Sq-E-d i{$ S \rf€ IIt Rqq 6sw aM 31punq*ft{qdffici oqt oq frq s{ fsr{-d i|-6 g6r d sf{ a * erf qftcr { e-ge i{rrs fl s*rd e}d efffi o€ atr $l g.16rq T, luia-cr ue rytcr.conion 1r+n qfu d srflqr frn+ srq tqfu 6) frqr qrflr t ql ss qfl { frrq qfuon cr d rff srrqy{--fl dfi r "**i-"f lmportant lf the within written receipt is signed by more than one person and payment is desired to bs made to only ono of them thsn the following note ofauthority must be completed and signed byallofthem before a magistrate orto aJustice of peaceorGazetted officer or a Block Development Otficer or a Principal/Headmasts of Local High School or Higher Secondary school run by the Government orAgenl of a Nationalised Bankora class-lofficer of the Corporation ora Deveiopmenr ofiiceiortne corporation with at least live year's service provided he/she is tully satisfied about the identity of the executants The letter of Authoriv will also be required if paymentisto be madetoany person otherthan the signalorios or the recerpt. . f,/sq gff{ rmr qrrfrq ftrq qq11}rr:n qll sTForr ;; ;;; ;;;;; ;;; ;; fur Ven t fr sq$-ffi ;n",n""I"fl;;;; Rs ;; ;;;;;,; ;;;;;; ;;;; ;T*"ffi"il;l Address 5 arfrn ?Tr aTMl i f{-{.frlcrqRerft il fwrerq friq (cd}$'rt srcil frf gq arftf, sT =Trq) r Witness: (See introduction below) EnKilqN//Signature T{r qrq/Fuil Name- g3r oTrq,/FullName- T€rlOccupation TsII/Address------- trcn/Address----------:---------- qfur*e q qftgs ouo'fts $ rwrer* t cclFrd 6rdt Efr W qQ-6R rrr ftl F-flur d//rffi..........................:............. ..................;......... oi s+dam ycfrqd qrdqrqr { qrrw Rqr"m er gkT6/i sfi-q-dqfuqr qeilqt of voa orgr6pq5q qri+frc c-6qdt I r hereby certify that the contents of this Note of Authority were explained by me in vemacular to Shri/ agreed to payinent being made the party or parties authorised Signature of Witness tl Instructions: qr; oi-ion q-* F<flefi/Full Name..................... qfus q frs cr qlqcfud i{Ao.rQ qr go-e frors srFmr{r qr F{irrq aRr {qrfuc sa frflraq qI sqin qrtqR-6 G-qffiq d a {|${€-d +6 d \rf€ qI ftqq d nan a}off idffi qt ftqq { qftGz qt dfi-rrs3dffi, doq$dqciqs{rtcrdr6gorE} sftrsgrffio'frrql*cltq gutilqldg€didsqfuffi{ ftioriqGcr FFre-r This fetter ot authority must be signsd before a Magistrate or aJuslice of peace ora Gazetted Otficer or a PrincipayHsadmaster ot Local High Schoolor Higher Secondary School run by the Govornmentoran Agentof a Nationalised Bank ora Class I Otficer of the Corporation or a Development Ofricer of the Corporation with at least live years service provided hs/she is tully satisfied about the identity ot the executants. qRqffiq{ qri qrd qFR erRrl*c€orefi Gdd erdnrfrr qrcrlm$ t d gei6i mrqoqRqffiqt\ilRrs sitq +s ql rs!-s ft-6'rs offfi qr rroqBc olffi q1s** em dqrfuc erftq sq frqraq qt vq crqfud frqFTq S ctfFTtqrd/cqr{ft4lq-fi qr yT*rrE-d to d \'+€ st Rqq d eqq 4bn qffi S oq $ oq vta q14 *arrc r-e gor t'l am lrro-t rrnen d-fl qGc 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 Otticer or a Principal/Headmaster ol Local High Schoo/Higher Secondary School run by the Government or Officer of Nationalised BankorClass I Officerofthe Corporation ora Development Otficer of the Corporation with at least tive yeafs servicewhen the note ofAuthority is executed byan illitrate orvernacular knowing person (s)