FORM H
[See sub-paragraphs (2) and (3) of paragraph 13]
(To be submitted by the nominee/ legal heir of the deceased depositor)

[Name of the Deposit Office]
Serial No
Application for closing the account under the Capital Gains Accounts Scheme, 1988 by the nominee/legal heir of the deceased depositor
To
The Manager
[Name and address of the Deposit Office]
I/We, [Name and address of the nominee/ legal heir
of the deceased depositor] hereby apply in terms of sub-paragraph (2)/(3) of paragraph 13 of the Scheme to close the account/ accounts mentioned below, which is/ are maintained with your office in the name of the deceased depositor [Name and address of the depositor and PAN and Distt / Ward/ Circle/ Range where assessed]
2 In terms of sub-paragraph (6) of paragraph 11, I, [Name of the nominee]
aged years, son of [full address] am entitled to obtain payment due to the credit in the account/ accounts mentioned under column 4 here under (in case application is made by the nominee)
3 I, [Name of the legal heir], aged years, son
of resident of [full address]
am making this application to obtain the payment due to the credit in the account/ accounts mentioned
under column 4 hereunder and submit herewith the letter(s) of disclaimer given by all other legal heirs
4 Details of Account/ Accounts
(i) Account -A No Pass book No
(ii) Account-B No Deposit Receipt No
5 I/ We tender here with the Pass book/ Deposit Receipt mentioned here in above
Signature/Thumb impression of the Nominee/
Legal heir of the deceased depositor
Date :
Place : Additional specimen
APPROVED
[Signature (with date) and stamp of Assessing Officer having jurisdiction]
FOR THE USE OF DEPOSIT OFFICE
(Details of Account/Accounts closed and total amount paid to the nominee /legal heir, may be recorded)
Date
Officer-in-charge
Notes:
1 Delete whatever is not applicable
2 Pass Book/Deposit Receipt, as the case may be, should be enclosed
3 Column 2 pertains to claim made by nominee and column 3 pertains to claim made by legal heir(s)
Hence, the column which is not applicable may be scored out