New Hope - Ex-gratia Application Form

Name of the Applicant (or) Nominee of the deceased :

Applicant’s Address

Ex – gratia claimed on behalf of Mr/Mrs :

New Hope membership Number of the deceased person :

Year of Joining of the deceased in New hope project :

Date of Death :

Reason of Death :

If accident death, date of accident :

Has the deceased got any Insurance Policy in Government / Private sector ?

Yes No

Relationship of the Nominee to the deceased :

Account Number of the Nominee : SB / CA

Name of the Bank your mission maintain Accounts :

Bank Name :

Branch :

IFSC No :

Name and address of the Introducer of the Nominee : (Introducer must be a member of new hope)

Introducer’s membership Number in New Hope

Attachment :

Death Certificate from Government agency

Membership Identity card of New Hope Project

Recommendation and Introductory letter from a New Hope member for the Nominee

Nominee’s passbook copy – front page with photo.

Place

Date

(Applicant’s Signature)

Nominee’s Photo Attested by a contributor member of New Hope

Attester’s membership Number in New Hope :

Attester’s Name

Signature

(Note : Providing falsehood would results in confiscation of attester’s future benefits from New Hope)

Sanctioned Rs

Approved on

Office seal

Rs. In words :

Signature of Director

Signature of Secretary

Signature of Treasurer