FORM 5
[See para 8]
Cancellation or Variation of Nomination previously made in respect of Account No. under Deposit Scheme for Retiring Employees of Public Sector Companies, 1991

To
The Manager,
(Name of the Bank)
(Address)
I, the depositor under Deposit Scheme for Retiring Employees of Public
Sector Companies, 1991, Account No. hereby cancel the nomination, dated made
by me in respect of the aforesaid account.
In place of the cancelled nomination, I hereby nominate the person(s) mentioned below who shall, on my death, become entitled to the payment of the sum due on the above account, to the exclusion of all other persons.
Serial
No.
Name of the
nominee(s)
Full address(es) Date of birth of
nominee(s) in case of
minor
Proportionate amount for
each nominee
To be filled in case of variation only.
As the nominee(s) at Serial No.(s) is/are minor(s). I appoint Shri/Smt./Kumari
(Name and full address) as the person to receive the sum due on the account in the event of my death during the minority of the nominee(s).
Signature or Thumb
impression of depositor
Depositor’s address
(1) Witness:
Name: .
Address:
(2) Witness:
Name: .
Address:
FOR THE USE OF ACCOUNTS OFFICE
The above cancellation/variation of the nomination has been registered in the ledger and entered in the pass book.
Date Signature of Authorised Officer
Delete if not applicable.