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You to pay the prizes (Rupees of Rs. to which I am entitiled. PARTICULARS OF PRIZE WINNING BONDS Rs. Denomination of Bond(s) Series and No. of Bond(s) Date (s) of issue (xx-xxxxxx) (dd-mm-yyyy) Place(s) of issue. Number and date of draw in which prize was/were won No. Amount of Prize(s) claimed. Date Rs. I declare that the Bond(s) was/were purchased by me on or before (dd-mm-yyyy) Signature or thumb impression of claimant Address: Name ( in block letters) ID Card No. or attestation D.

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