FORM C
Serial No……………………
APPLICATION FOR NOMINATION/CHANGE/CANCELLATION OF NOMINATION UNDER SENIOR CITIZENS SAVINGS SCHEME, 2004

To
The Postmaster/Incharge
…………………………………. (name of the Deposit Office)
………………………………….
Sub : Application for Nomination or change/cancellation of Nomination
Sir
1. I, ………………………………………… hereby nominate the following person/persons mentioned below, to whom, to the exclusion of all other persons, in the event of my death the amount standing to my credit in account no…………………. would be payable in accordance with the provisions contained in rule 6 of Senior Citizen's Savings Scheme, 2004.
Sl
Name(s) of the nominee(s)
alongwith relationship with
the depositor(s)
Permanent Address
Date(s) of birth of
nominee(s) in case of
a minor/age in other
case(s)
Share of nominee(s) in
amount payable
2. As the nominee(s) at Serial No.(s) ……………………………… above is/are minor(s), I appoint Sri/Smt/Kumari ………………………………………………. [name(s) in full with complete address(es) of the person(s) in respect of each minor nominee] to receive the sum due under the said account in the event of my death during the minority of the nominee(s).
3. This is in supercession of the nomination(s) made by me earlier at the time of opening of account/vide my application dated ………………………
4. I……………………………………. hereby request to cancel the nomination made by me earlier vide application dated ………………………..
Witnesses [Signature, name and address]
1 Signature of the Depositor
(Name and Address)
2
Date ………………… at place ………………
Score out whichever is not applicable
------------------------------------------------------------------------------------------------------------------------------
FOR THE USE OF DEPOSIT OFFICE
The above nomination has been registered on ……………………….. AND/OR the earlier nomination dated ………………………. has been changed/cancelled. Necessary entries have been made in the Passbook (No……………...……….) and relevant Ledger folio No…………… accordingly.
Date Signature of incharge of Deposit Office
(along with name and designation stamp)