Annexure 4A
Application for Deceased Claim from Legal Claimant
[Holder of Succession Certificate, or Letter of Administration, Court Order or Probate of Will]
From
___________________
___________________
___________________
To
The Branch Head
Axis Bank Ltd.
___________________ Branch
Dear Sir,
Re: Deceased Account
Late Shri/Smt. ________________________________________________________
Account No(s)
_______________________________________________________________________
Term/Fixed Deposit No(s)
_______________________________________________________________________________
I/We advise the demise of Shri/Smt. _______________________ on __________________. He/she,
they hold the above account(s)/term/fixed deposit(s) at your branch. The account(s)/term/fixed
deposit(s) is/are in the name(s) of
_________________________________________________________________________with MOP
as ______________________.
I/We submit photocopy of the following document(s) together with originals. Please return the original
to us after verification.
i. Death Certificate issued by ______________________
ii. Identity proof (required in nomination cases) ________________
I, ________________________________ son/ daughter/ Wife of Shri
___________________________ residing at ______________________________________. hereby
declare that I have received the legal representation from the appropriate authority entitling me to
receive from your Bank the balance(s) in the account(s) with the Bank in the name of
________________________, the deceased.
I/We lodge my / our claim for the above balances with accrued interest of the above-named deceased
in terms of legal representation by way of: (Select whichever is applicable)
Will of the late Shri / Smt. / Kum. ______________________dated _______________ and a
Probate granted by the Court of _____________ at __________________________ dated
____________________________________________ (Copy enclosed).
Succession Certificate dated ___________________ granted by the Court of
________________________at _____________________________ (Copy Enclosed).
1
Letters of Administration No ____________________________ dated ___________ issued
by Court of
_____________at ____________________________________________________ (Copy
enclosed).
Court order No ____________________________ dated ___________ issued by
Court of _____________at ____________________________________________________ (Copy
enclosed).
Accordingly, I hereby submit my claim and furnish the requisite particulars / documents for deceased
claim settlement for payment as per the Bank’s rules & discretion.
I am / We are aware that the deceased holder had certain outstanding amounts (“Outstanding Dues”)
payable to the Bank in relation to certain credit facilities availed by him/ her and/ or certain other dues
payable to the Bank. I / We hereby authorise the Bank in exercise of its right to lien and set-off in
accordance with the terms of the loan agreement executed, to deduct the Outstanding Dues from the
total available balance held by the deceased holder in the aforesaid account(s)
Pay the Proceed by:-
DD to be issued in favour of:
___________________________________________________________
or
A/c No for fund Transfer:
_______________________________________________________________
I/We lodge our deceased claim settlement for payment as per the Bank’s rules & discretion.
My/our contact details is/are as below:
Name of the Claimant : _____________________
Mobile Number of Claimant : ______________________
Email id of Claimant : _____________________________
I hereby authorise Bank to send communication regarding claim settlement related to above
mentioned account(s) to my contact number/email id mentioned herewith.
I/We hereby solemnly affirm that the above statements are true and correct to the best of my/our
knowledge and belief.
Place: ____________________________ Yours faithfully,
Date: _____________________________ (Claimant(s))
2
For Office Use
Documents Received Date: - ____________
Name of Customer (Deceased): __________________________________ CIF:
_____________________
Date of Death: ____________________ Date of Intimation to Bank: ____________________
Name of Claimant(s): _____________________________________________
Certification by Branch Head:
Certified that due diligence and discrete enquiry have been made to identify the claimant(s).
All the documents have been verified with the original (wherever applicable).
Branch has done discreet enquiry about the genuineness of the order and certified copy of the Order.
Claimant name as per system is ______________________________ and as per OVD proof
is __________________________, Due diligence is done, and we confirm that both the
persons are same.(in case of name mismatch)
Deceased name as per system is ___________________________ and as per Death
Certificate is __________________________, Due diligence is done, and we confirm that
both the persons are same. (in case of name mismatch)
Signature: Signature:
(Sign Verification / Prepared by BOH) (Approved by Branch Head)
Grade: Grade:
Employee code: Employee code:
Death Certificate
Probated will/Succession Certificate/ Court Order/ Letter of
Administration Received
Claim Form (Annexure- 4 A)
Deceased claim settlement
through legal representation OVD of Claimant/s
SB Account Closure Form
In case of FD, FD Receipt or FD advice(as applicable) signed by
claimant/s
Annexure - 7 Receipt – To be collected from claimant once the
settlement is done.
