FORM G
[See sub-paragraphs (5) of paragraph 12]
STATE BANK OF .
Application for withdrawals by nominees/ legal heirs under
the Public Provident Fund Scheme,1968

To
The Agent/Manager,
State Bank of
I/ We, , the nominee(s)/ legal heir(s) of late , the subscriber to Public Provident Fund Account No. wish to withdraw the entire amount standing to the credit of the deceased in the said account.
Please find enclosed :
(i) A certificate in regard to the death of the subscriber.
(ii) Certificate in regard to the death of Shri and Shri also the nominee(s) appointed by the subscriber.
(iii) Succession certificate/ Letters of Administration with attested copy of the probated will of the deceased subscriber issued by High Court.
(iv) Pass Book of the subscriber.
@ (v) Letter of indemnity.
@ (vi) Affidavit.
@ (vii) Letter of disclaimer on affidavit.
Place .
Signature(s)/ thumb impression of claimant(s)
Date .
Delete if not applicable.
Strike off if there is a valid nomination.
@To be produced by legal heirs, in the absence of nominations, for claims up to Rs. 1 lakh.
FOR USE OF ACCOUNTS OFFICE
Withdrawal of Rs. (Rupees ) is
sanctioned.
Date . Accounts Officer
RECEIPTS TO BE SIGNED BY THE CLAIMANTS
Received the sum of Rs. (Rupees ) from the State
Bank of in full settlement of our claim.
Place . STAMP
Date . Signature(s)/ thumb impression of claimant(s)
ANNEXURE 1 TO FORM G
LETTER OF INDEMNITY
To
The Manager/ Post Master,
(Name of the bank/ head post office)
In consideration of your paying or agreeing to pay me/ us (Names of legal
heirs) the sum of Rs. standing in Public Provident Fund Account No. with your
Bank in the name of without production of letters of administration or
a succession certificate to the estate of the deceased (Name of the
subscriber) or a certificate from the Controller of Estate Duty to the effect that estate duty has been paid or will be paid or none is due, I/we and we (sureties) do hereby for ourselves and our heirs, legal representatives, executors and administrators jointly and severally undertake and agree to indemnify you
and your successors and assigns against all claims, demands, proceedings, 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 sum as aforesaid.
In witness whereof we have hereunto set our hands at on this day
of in the presence of witnesses.
Signed and delivered by the above-named heir/ heirs of the deceased
Signed and delivered by the above-named sureties:
1.
2.
Names and addresses of witnesses:
1.
2.
Attested
NOTARY PUBLIC
ANNEXURE II TO FORM G
AFFIDAVIT
To
The Manager/ Post Master,
[Name of the bank/ head post office]
I/ We, husband of/ wife of late aged, aged, aged sons/ daughters of the said late residents of , do hereby declare and solemnly affirm as under:
(1) That I/we am/ are the only heir(s) of the deceased who died at on I/ we alone represent the estate of the deceased Sh./ Smt .
(2) That the deceased did not leave any will and, therefore,
I/ we am/ are the only successor(s) to the estate of the said deceased.
Deponents
VERIFICATION
I/We, the above-named deponents do hereby verify on solemn affirmation in (name of place) that the contents of this affidavit are true to our knowledge and nothing material has been concealed.
Dated .
Deponents
ANNEXURE III TO FORM G
LETTER OF DISCLAIMER ON AFFIDAVIT
To
The Manager/ Post Master,
[Name of the bank/ head post office]
I/ We (i), husband of/ wife of residents
of (ii), son of/ daughter
of , (iii) son of/ daughter of , do hereby solemnly affirm and declare as follows:
(1) That Sh./ Smt died intestate on leaving behind us his only heirs.
(2) That we heirs of our late father/ mother for ourselves and on behalf of our heirs, executors, representatives and assigns do hereby relinquish our claims to the balance of Rs. which may be credited to the account sought by our mother/ father to be opened in your Branch in the name of the estate of the said deceased father/ mother after the realisation of Draft No. on issued by [Name of bank] and we have no objection whatsoever to the balance in the above-referred Account No. together with interest, if any, accrued thereon being paid by the Bank to our said mother/ father Mrs./ Mr. .
Deponents
VERIFICATION
We, the above-named deponents do hereby verify on solemn affirmation that the contents of this affidavit are true to our knowledge.
Dated ..
I identify the deponent who is personally known to me and who has signed in my presence.
Dated .
Attested
OATH COMMISSIONER