Lic Surrender Form 5074 Pdf Details

Are you looking to surrender your driver's license in Missouri? If so, you'll need to complete the Lic Surrender Form. This form can be downloaded from the Missouri Department of Revenue (DOR) website. In this article, we'll provide a brief overview of the Lic Surrender Form and what it entails. We'll also provide instructions on how to complete the form.

Below is the data in regards to the file you were seeking to complete. It will tell you the span of time you will need to fill out lic surrender form, what parts you will need to fill in and some further specific details.

QuestionAnswer
Form NameLic Surrender Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameslic withdrawal form, lic surrender form, lic of india policy surrender form, surrender form lic

Form Preview Example

_____________ DIVISIONAL OFFICE

FORM OF RECEIPT FOR THE SURRENDER VALUE OF POLICY NO.

--------------------------------------------------------------------------------------------------------------------------------

On the Life of ________________________________________________________________

For Rs._____________________________________________ dated __________________

I/We hereby declare that I/We have not served on any Office of the Life Insurance Corporation of India any Notice of assignment or reassignment in respect of the above POLICY/ POLICIES except those, if any already Registered by the Life Insurance Corporation of India or the Insurer who issued the above POLICY/POLICIES nor Shall I/We serve on any office of the said Corporation, any notice of assignment or reassignment before payment of the Loan Value/ Surrender Value or Survival benefit due on ________________________________ I have not

dealt with the Policy in any other way.

I/We_________________________________________________________________________

____________________________________________________________________________

do hereby acknowledge receipt from the Life Insurance Corporation of India of the sum of Rupees

*___________________________________________________________________ being the Surrender Value including Cash Value of Bonus and premiums refundable on account of occupation extra and / or DAB/EPDB extra of the above

Mentioned Policy, which is herewith delivered up to the said Corporation to be cancelled. In

witness whereof these presents are subscribed by me/us.

at_________________________________________________________________________on

Name of the place

the ______________________________day of _________________________________2000

Date

Month

SURRENDER VALUE (Inclusive of Cash Value of Bonus )

Rs. ______________

Premium refundable on account of occupation extra

Rs._______________

Premium refundable on account of D.A.B. / EPDB extra

Rs. _______________

Less :

 

Loan

Rs. _______________

Interest

Rs. _______________

APL Debt

Rs. _______________

Other Charges (to be specified )

Rs. _______________

 

Rs. _______________

 

Rs. _______________

ENGLISH-KNOWING WITNESS :

 

 

Signature : _____________________________

 

One Rupee

 

 

Revenue

 

 

Full Name : _____________________________

 

Stamp

 

When

 

 

 

 

amount

 

 

 

 

exceeds Rs.

 

500/-

(of the witness)

 

 

 

Occupation : ____________________________

 

 

 

Address : ____________________________

Signature

In Short in

English

______________________________________

 

Full

Vernacular

______________________________________

 

 

 

___________________________________________________________________________

* Gross amount of Surrender Value

* Delete where not applicable

___________________________________________________________________________

Note : Illiterate persons must affix their thumb marks which should be indentified by the attesting Magistrate under the seal of his office, or a Block Development Officer or a Gazetted Officer or a Principal/Headmaster of Local High School or Higher Secondary School run by the Government or an Agent of a Nationalised Bank or Class I Officer of the Corporation or a Development Officer of the Corporation with atleast Five Years' Service provided he/she is fully satisfied about the identify of the person(s) executing the form. Signature in Regional Languages must be attested by respectable English-knowing persons. The witness attesting such Signatures/thumb marks should sign the declaration below :-

"The contents of this discharge form have been explained to ____________________________

______and he/she/they have/has signed the same/put thumb impression after fully understanding

the same.

SEAL OF OFFICE

______________________

IF ANY

 

 

Signature of the Witness

If the Receipt is signed by more than one person and payment is desired to be made to only one of their number, then a letter of Authority as under must be completed and signed by all of them except the authorised person before Magistrate or a Block Development Officer or Gazetted Officer or a Principal/Head Master of Local High School or Higher Secondary School run by the Government or an Agent of a Nationalised Bank or a Class I Officer of the Corporation or a Development Officer of atleast 3 years' standing or confirmed Dev. Officer recruited from Agents who were D.M.'s or B.M.'s Club Members before joining provided he/she is fully satisfied about the identity of the executants. The Letter of Authority will also be required if payment is to be made to any person other than the parties signing the Receipt.

Place__________________

Date __________________

I/We hereby authorise and request Life Insurance Corporation of India to pay the above mentioned amount of Rs. ______________________________________________________

to ________________________________________________________________________

(Name of the authorised person)

Signed by the party or parties

Within-mentioned in the presence of :

______________________

Signature/s in full

__________________________________________________________________________

Magistrate or a Block Development Officer or a Gazetted Officer etc.

??I hereby certify that the contents of this note of Authority were explained by me in vernacular

to

____________________________________________________________________________

____________________________________________________________________________

and he/she has agreed to payment being made to ____________________________________

They have

______________________________________the party or parties authorised.

Magistrate or a Block Development Officer or a Gazetted Officer etc.

____________________________________________________________________________

??This endorsement is required to be completed and signed by the attesting Magistrate, or a Block Development Officer or a Gazetted Officer etc. when the Note of Authority is completed by an illiterate or Vernacular knowing person.

F.No. 5074/3510 (Rev.)

___________________

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