AFFIDAVIT –CUM-IDEMNITY BOND

I, Mr. KUMARA, S/o Krishnappa Gowda, residing at Door No. 4-43, Alike Mura house,
Mooduperar Village & Post, Mangaluru Taluk, D. K. District, Karnataka State solemnly affirm
and state an oath as under:-
1) I state that I was employee with M/s. Raj clay Products 2016 and holding P.F. Account
No. with the Regional Provident Fund Commissioner Maharashtra.

2) I hereby undertake and indemnity, to Central Board of Trustees, Provident Fund

Organization for any claim later if found false, for any loss incurred out of this transaction.

3) I declare that I have not withdrawn my P.F. accumulation/withdrawal benefit of FPF/EPS

95 till date.

This Affidavit-cum-indemnity bond has been executed by me and state that the facts
mentioned herein before are true and correct to the best of my acknowledge and belief.

DEPONENT
 DRAFT OF INDEMNITY BOND TO BE OBTAINED BEFORE ISSUING A
DUPLICATE POLICY CONSEQUENT ON THE LOSS OF THE ORIGINAL POLICY
BOND
Know all men by these present that I, MURALIDHARA SHETTY, aged
about 31 years, S/o Yashodhara Shetty, residing at
…..2

-: 2 :-
Barke House, Muloor Village, Gurupura Post, Mangaluru Taluk D.K. District is the
policyholder of a Life Insurance Policy bearing no. 01709236 and assuring a sum
of Rs. 23,800/- (Rupees Twenty Thousand Eight Hundred only) issued by M/s.
Exide Life Insurance Company Limited, having its registered office at 22, M. G.
Road Bangalore-560001, hereinafter referred to as the Company.

Whereas the above noted policy bearing no. 01709236 issued by the
Company has been lost irretrievably and on my request the said Company has
agreed to issue a duplicate of the said policy no. 01709236 subject to my
undertaking to indemnify the Company against any claim that may be made on
the basis of the policy bond bearing no. 01709236 which has been lost and also
further agreeing to indemnify the Company against any consequential
losses/damages/expenses.

I, MURALIDHARA SHETTY therefore hereby agree and bind myself, my heirs,

successors, legal representatives, administrators, assigns, to M/s. Exide Life
Insurance Company Limited For all the amounts that may become payable on the
policy of Insurance bearing no. 01709236 and also agree to indemnify and keep
indemnified and keep indemnified the Company, its officers and agents from all
actions, suits, costs, claims and demands of whatever nature or kind which may be
instituted, preferred, claimed or made against the Company, its successors or
assigns by any person or persons by reason of his, her or their possession of or
right to the said original policy bearing no. 01709236.

Signed in the presence of presence of witnesses and delivered at Bangalore

on this 01st day of October, 2019.

Signature of Policyholder
Witnesses:-

1. 2.

AFFIDAVIT –CUM-IDEMNITY BOND

 I, Mr. SAVUL HAMEED, S/o. Shekabba, residing at Kinnimajal house, Moolur Village,
Gurupura Post, Mangaluru Taluk, D. K. District, Karnataka State solemnly affirm and state an
oath as under:-
4) I state that I have worked in M/s. First Source Solutions Ltd. Upto 11 th March 2016 and
holding P.F. Account No. with the Regional Provident Fund Commissioner
Maharashtra.

5) I hereby undertake and indemnity, to Central Board of Trustees, Provident Fund

Organization for any claim later if found false, for any loss incurred out of this transaction.

6) I declare that I have not withdrawn my P.F. accumulation/withdrawal benefit of FPF/EPS

95 till date.

This Affidavit-cum-indemnity bond has been executed by me and state that the facts
mentioned herein before are true and correct to the best of my acknowledge and belief.

DEPONENT

AFFIDAVIT CUM INDEMNITY BOND

(In case of Loss of Original Scheme Certificate)

I, Mrs. MARIYAMMA, aged about 58 years, W/o. G. Abdul Hameed, residing a

Kottari Gudde house, Mulloor Village, Gurupura Post, Mangaluru Taluk, D.K. State o
Solemn Affirmation as under:-
…..
 -: 2 :-
7) I say that, I Mrs. Mariyamma, W/o. G. Abdul Hameed was working in M/s. Metr
Beedi Works, and holding Pension Fund No. A/C. No. KN/6223/125 with regiona
Provident Fund Commissioner, Depot, Mangalore, Dakshina Kannada.
8) I say that I the said member was issued a Scheme Certificate under para12(8) o
Employees Pension Scheme 1995 after exit from the above stated establishment.
9) I state that the above Stated Scheme Certificate has been Lost/ irretrievabl
misplaced.
10) I state that if the above stated Scheme Certificate is found in a later date it wi
not be utilized and shall be surrendered to the office of the Employees Providen
Fund Organization.
11) I further indemnify the Central Board of Trustees, Employees Provident Fun
and Keep them indemnified against the above loss that it may incur in future by wa
of inadvertently granting pension against the above stated original Scheme Certificat
reported to have been lost/ Misplaced.

This Affidavit Cum Indemnity Bond has been executed by me and I do state tha
the facts mentioned herein before are true and correct to the best of my Knowledg
and belief.

DEPONENT
Solemnly affirmed and signed before me, after the contents of this affidavit rea
over to the deponent in Kannada, the language known to her and admitted by her a
true and correct on this 14th day of November, 2018 at Mangaluru.

Signature of two Sureties

with name and Address:- 1.

2.

Identified and explained by me:

Advocate
 AFFIDAVIT CUM INDEMNITY BOND
(In case of Losss of Original Scheme Certificate)

I, Mrs. DEVAKI, aged about 50 years, W/o. Sundara Gowda, residing at Nea
Garadi, Tenka Yedapadavu Village, Shibrikere Post, Mangaluru Taluk, D.K. State o
Solemn Affirmation as under:-
…..

-: 2 :-

12) I say that, I Mrs. DEVAKI, W/o. Sundara Gowda, was working in M/s. Prakas
Beedi Works and holding Pension Fund No. A/C. No. KN/6225/23070 with regiona
Provident Fund Commissioner, Depot, Mangalore, Dakshina Kannada.

13) I say that I was issued a Scheme Certificate bearing No. KN/MN 34875 unde
para12(g) of Employees Pension Scheme 1995 after exit from the above state
establishment.

14) I say that the above Stated Scheme Certificate has been Lost/ irretrievabl
misplaced.
 15) I state that if the above stated Scheme Certificate is found in a later date it wi
not be utilized and shall be surrendered to the office of the Employees Providen
Fund Organization.

16) I further indemnify the Central Board of Trustees, Employees Provident Fun
and Keep them indemnified against the above loss that it may incur in future by wa
of inadvertently granting pension against the above stated original Scheme Certificat
reported to have been lost/ Misplaced.

This Affidavit Cum Indemnity Bond has been executed by me and I do state tha
the facts mentioned herein before are true and correct to the best of my Knowledg
and belief.

DEPONENT
Solemnly affirmed and signed before me, after the contents of this affidavit rea
over to the deponent in Kannada, the language known to her and admitted by her a
true and correct On this 17th day of October, 2016 at Mangalore.

AFFIDAVIT CUM INDEMNITY BOND

(In case of Losss of Original Scheme Certificate)

I, Mrs. JACINTHA, aged about 59 years, W/o. William Fernandes, residing at Doo
No. 1-257/2, Korakambla House, Bajpe Village & Post, Mangaluru Taluk, D.K. State o
Solemn Affirmation as under:-
…..
 -: 2 :-

17) I say that, I was working in M/S. Joonktollee Tea & Industries Ltd. Goomankha
Estate, Hirebyle and holding Pension Fund No. 2618 with the regional Provident Fun
Commissioner, Dakshina Kannada.

18) I say that I was issued a Scheme Certificate under para12(8) of Employee
Pension Scheme 1995 after exdit from the above stated establishment.

19) I say that the above Stated Scheme Certficate has been Lost/ irretrivabl
misplaced.

20) I state that if the above stated Scheme Certficate is found in a later date it wi
not be utilized and shall be surrendered to the office of the Employees Providen
Fund Organization.

21) I further indemnify the Central Board of Trustees, Employees Provident Fun
and Keep them indemnified against the above loss that it may incur in future by wa
of inadvertently granting pension against the above stated original Scheme Certificat
reported to have been lost/ Misplaced.

This Affidavit Cum Indemnity Bond has been executed by me and I do state tha
the facts mentioned herein before are true and correcty to the best of my Knowledg
and belief.

DEPONENT
Solemnly affirmed at Gurupura Kaikamba, Mangalore Taluk, On this 17 th day o
June, 2016.

Signatures of Two Sureties with name and Address:-

1.

2.

Identified by me,

Advocate
 AFFIDAVIT CUM INDEMNITY BOND
(In case of Losss of Original Scheme Certificate)

I, Mrs. SAMPA, aged about 53 years, W/o. Lakshmana Shetty, residing at Pallipad
Poilody House, Badaga Bellur Village & Post, Bantwala Taluk, D.K. State on Solem
Affirmation as under:-
…..

-: 2 :-
22) I say that, I was working in M/S. Bharath Beedies Private Ltd. Mangalore an
holding Pension Fund A/C. No. KN/MLR/75225 with the regional Provident Fun
Commissioner, Dakshina Kannada.

23) I say that I was issued a Scheme Certificate under para12(8) of Employee
Pension Scheme 1995 after exdit from the above stated establishment.

24) I say that the above Stated Scheme Certficate has been Lost/ irretrivabl
misplaced.

25) I state that if the above stated Scheme Certficate is found in a later date it wi
not be utilized and shall be surrendered to the office of the Employees Providen
Fund Organization.

26) I further indemnify the Central Board of Trustees, Employees Provident Fun
and Keep them indemnified against the above loss that it may incur in future by wa
of inadvertently granting pension against the above stated original Scheme Certificat
reported to have been lost/ Misplaced.

This Affidavit Cum Indemnity Bond has been executed by me and I do state tha
the facts mentioned herein before are true and correcty to the best of my Knowledg
and belief.

DEPONENT
Solemnly affirmed at Gurupura Kaikamba, Mangalore Taluk, On this 29 th day o
July, 2013.

Signatures of Two Sureties with name and Address:-

1.

2.

Identified by me,

Advocate
 AFFIDAVIT

I, Mr. KESHAVA SAPALIGA, aged about 58 years, S/o. Babu

Sapaliga, residing at Nithin Nivas, Kondodi, Tenka Yedapadavu Village
Shibrikere Post, Mangalore Taluk, D.K. do hereby solemnly affirm and stat
on oath as follows:-
…..

-: 2 :-

27) I say that I am the deponent herein and father of DEEPAK. I sa

that since my son is working at Mumbai I am swearing this affidavit on
behalf of him.

28) I say that, my son Deepak studied up to 9 th Standard at Mukth

Prakash High School, Neerude-574163, Mangalore Taluk, D.K in the yea
1999-2000.

29) I say that original Transfer Certificate bearing No. 65/2003-04 dated
08.11.2003 issued by the said School has been lost in his hands behind
Recovery.

30) I say that my son Deepak is in need of Transfer Certificate fo

applying for Passport and all other future purposes.

31) I say that I swear this affidavit for the purpose of issuance o
Duplicate Transfer Certificate of my son Deepak.
32) I say that myself and my son will undertake to surrender the origina
Transfer Certificate in case the same has been traced in future.

33) I say that all these stated above are true and correct to the best of m
knowledge and belief.

I therefore pray before you to kindly issue me Duplicate Transfe

Certificate of my son Deepak.

DEPONENT
Solemnly affirm and singed before me, after the contents of thi
affidavit read over to the deponent in Kannada the language known to him
and admitted by him as true and correct on this 21 st day of March, 201
at Mangalore.