DEPARTMENT OF POST, INDIA

OFFICE OF THE CHIEF POSTMASTER, GPO

To,
The Postmaster
______________
______________
Sir,
The payment of ________________________________ balance at the credit of savings/SB/
TD/CTD/MIS/PPF A/C No. ___________________________________
• Payment of the value of the Post Office Certificate details below :-
A. List may be attached separately,
Sl. No. Cert. No. Fee Value Rs. Regn. No. Post Office
1
2
3
4
5
Total
• In support of the claim I/we hereby submit :
a) The Pass Book A/c No. :
Type of A/c :
Post Office :
b) Photostat copies of the Savings Certificate :
• Death Certificate of the Depositor
a. Name of deceased (Block Letter) ________________________________
b. Date of Death ______________________
• Certified of death of the other nominee(s) if any the nomination was registered at Post
Office under nomination Regn. No.
Date of Nomination ________________________
Yours Faithfully

(Signature of claimant)
Name (In Block Letter) ______________________
Address __________________________________
_________________________________________
_________________________________________

The claimant is known to me personally and the above statement has been signed in my presence

Witness 1 :
Signature : ___________________________
Name _______________________________
Address _____________________________
____________________________________
Witness 2 :
Signature : ___________________________
Name _______________________________
Address _____________________________
____________________________________