Proforma no.

4
AFFI DAVIT
1) ______________________son of __________________ Resident
of___________________________
2) ______________________son of ____________________
Resident of______________________________________
Here by made oath/solemnly affirm and say as follows:-that Shri
_________________________(name of the deceased) hereinafter referred to as the
deceased) died intestate on _____________________at_______________________
That we know the deceased and his family since the
last__________________________________years.
That at the time of his death the deceased left surviving the following persons who according
to the law by which they governed, are the only legal heirs of the deceased entitled to succeed
to the estate of the deceased on an intestate succession.
a) _________________________(state the name, age,
b) ________________________(Relationship of each
c) _______________________of the persons with
d) ________________________the (deceased)
3) That we are not related in any manner whomsoever to the deceased or any of the above
mentioned persons not have we any claim or interest of whatsoever nature in the estate of the
deceased.
4) That we are informed and we verily believe that the deceased has left certain deposits/assets*
with the Andhra Pradesh Grameena Vikas Bank ___________________Branch to which the
above mentioned persons are entitled to claim.
5) That we are making this solemn declaration sincerely and conscientiously believing the same to
be true with a full knowledge that it is on the strength of this declaration that the Andhra
Pradesh Grameena Vikas Bank _________________Branch, has agreed at our request to make
payment of amount of the deposits/to deliver the assets to the above mentioned persons
without insisting on production by them of a grant of legal representation to the estate of the
deceased from a competent court.
Solemnly affirmed on this _____________day of ___________Two
thousand___________________ at ______________________in the
1. 2.
(Signatures of persons sworning ) signed before me
Signature of judge/Magistrate/
Notary Public*

DELEFT WHICHEVER IS NOT APPLICABLE

This Affidavit should be obtained from two respectable persons of the village who are not related to
each other or to the family of the deceased, or to the proposed two sureties. This must be sworn
before a judicial Magistrate/Notary Public.

Proforma no. 5
LETTER OF DISCLAIMER
PLACE:
DATE:
To
The Branch Manager,
Andhra Pradesh Grameena Vikas Bank,
_________________________Branch.
Dear sir,
___________________________A/c No.
In the name of _________________________(Now deceased)
With reference to the above account(s), I/we the following legal heirs of the late account holder of either
deposit account or gold loan account or both) have to state that we/I have no interest in the above
assets and as such We/I have no objection to your paying the balance amount lying in the above account
with you in the name of the aforesaid
Shri
____________________________(name of the deceased
________________________________________account holder)/delivering the gold ornaments pledged
by late Shri
__________________________(name of the deceased) to shri
_______________________________such delivery of the
Ornaments/payment of the balance in the above account would be completely binding on us and we/I
will not question the Banks action in so doing, in any proceedings. I/we also u undertaken to the bind
myself/ourselves, our heir and legal representatives not to revoke the declaration made herein.
Sl.No. Name of the Claimants Age Signature
1.
2.
3.
Signed before me at ___________(place)on this __________day of _________________Two
thousand________________________________________
Signed of Notary Public/Magistrate
Fill in the type of account viz., CA/SB/TD/STDR/RD/CASH Certificates /Gold loan account.
Note: 1. this let4er should be executed by Legal heirs, who claim their right to the assets of the
deceased, in favour of one legal heir or more.
2. Please note that only one disclaimer latter signed by the concerned legal heirs be obtained and
not individually to avoid expenditure to claimants.

PROFORMA NO. 7

RECEIPT TO BE OBTAINED IN CASE OF DEPOSIT ACCOUNT

Received a sum of Rs._______________(Rupees____________

________________________only) from the Branch Manager,
Andhra Pradesh Grameena Vikas Bank,__________________ Branch being the proceeds of the deposits
made /held by /on account of late shri ___________________________________
(give name of the deceased depositor)as detailed below together with Interest eligible and accrued
therein up to date in full settlement of the claim made in my/our favour.
Nature of Account Amount
PLACE:

DATE: (Signature(s) on Revenue Stamp by claimants)

PROFORMA NO.8

RECEIPT TO BE OBTAINED IN CASE OF

GOLD LOAN BORROWER
 Received complete and in order from the Branch
Manager, Andhra Pradesh Grameena Vikas Bank,__________________________Branch the following
gold ornaments pledge by the shri __________________________
_______________________________under gold loan account
No._________________Dated____________for Rs__________Description of the Ornaments Gross
weight of the ornaments

PLACE:
DATE: (SIGNATURE OF CLAIMANTS)

PROFORMA NO.9
(To be stamped as on Agreement i.e.., Rs . 100/-
LETTER OF INDEMNITY WITH RESPECT TO PAYMENT OF BALANCES IN DEPOSIT ACCOUNTS

PLACE:
DATA:

To
The Branch Manager,
Andhra Pradesh Grameena Vikas Bank,
____________________________Branch.

Dear Sir,

In consideration of your paying or agreeing to pay me/us _________........................................(insert

here the names or the heirs of the deceased) the sum of Rs.______________
(rupees_________________________________only) standing at the credit of current A/c/SB
A/c/RD A/C/TDR
A/C/STDR A/c cash Certificate A/c-no ________________dated ________for
Rs___________due on ____________________with your bank in the name of shri
_________________since deceased, without production of letters of administration or a succession.
Certificate to his/her estate or a certificate from the controller of Estate Duty to the effect that the
estate duty has been paid or WILL BE PAID OR
that none is due, I/we____________________________________(State here the names of the
heirs of the deceased) and we ______
_________________________________________(state here the names of the sureties) do hereby for
ourselves and our heir, legal representatives, executors and administrators, join and severally
UNDERTAKE AND AGREE to indemnify you and your successors and assigns against all claims,
demands, proceeding, losses, damages, charges and expenses which may be raised against or incurred
by you by reason or in consequence of your having agreed to pay/or paying me/us the said sum is
aforesaid.
Solemnly affirmed on this___________________day of Two thousand_____________________
signed and delivered
by the above named

(signatures of heirs of the deceased

Signed and delivered

By the named

(Signatures of sureties)