PRIZE MONEY CLAIM APPLICATION FORM – (PB-23)

The Chief Manager, State Bank of Pakistan, SBP Banking Services Corporation

________________________

Date D D - M M - Y Y CHECK LIST (please mark )

Original and Copy of Prize Bond □ Photocopy of valid CNIC/SNIC (original seen) □ 2 Signatures on reverse of Original & Copy of Prize Bond □

Dear Sir, I enclose herewith the __________ Number of National Prize Bond(s) of Rs. _______________ denomination particularized

below and request to kindly arrange payment of the prize money as the enclosed Bond(s) has/have been declared

winning in draw mentioned there against.

C L A I M A N T I N F O R M A T I O N Name (as per CNIC)

CNIC No - - CNIC Expiry Date

Address

Contact No.

Taxpayer Status ⎕ Filer ⎕ Non-Filer Email ID

P R I Z E B O N D D E T A I L S

S No. Prize Bond Details Date of

Issue

Draw No.

Place of Issue

Amount of Prize Money (PKR)

T-24 System ID (for office use only) Series Serial No.

1

2

3

4

5

6

7

8

9

10

Total Prize Money (PKR)

MODE OF PAYMENT OF

PRIZE MONEY

Up to PKR 18,500/- ⧠ Cash only ⧠ Bank Credit

PKR 93,000/- & above ⧠ Bank Credit ⧠ Payment Order

B A N K A C C O U N T D E T A I L S

Bank Name Branch Name

Account Title

IBAN P K

U N D E R T A K I N G I hereby declare and accept that:

1. The National Prize Bond(s) presented by me for prize money claim is/are “Genuine”. In case the bond(s) is/are found forged/tampered, SBP BSC (Bank) reserves the right to take legal action against me as per the relevant laws.

2. The information provided above shall deemed to be true & complete and any misinformation/incorrect details or concealment of facts of any nature whatsoever by me can result in legal action against me as per the relevant laws. In case of change in any of the aforementioned information including taxpayer status i.e. Filer / Non-filer, it shall be my responsibility to inform in writing the respective SBP BSC office immediately.

3. The aforementioned bank account is maintained singly in my name at the bank as stipulated above. 4. Any discrepancy found in the above bond(s) at later stage, the amount of prize money so released would be refunded by me. 5. In case of loss of payment order(s), duplicate instrument(s) will be issued against service charges of Rs. 200/- per payment order. 6. The Withholding Tax on prize money amount will be deducted at prevailing rates.

Signature / Thumb Impression of the Claimant Officer/S.O. (Original CNIC/SNIC Seen by SBP BSC Official)

D O N O T W R I T E B E L O W T H I S L I N E / F O R O F F I C E U S E O N L Y

No :- KHI/LHR-_____________________________________

Date of receipt of claim ______________________________________

System generated acknowledgment receipt issued to claimant:

⧠ YES (No._____________________) ⧠ NO (Reason) _____________________

PAID CASH STAMP (Upto Rs. 18,500/-)

(PB-23) (To be filled by the SBP BSC Office). The particulars of Prize Winning Bond detailed below of Rs. __________________ denomination attached with the claim application have been verified from our record and found in order in all respect / not found in order. The condition of the Bond is accepted / is not accepted.

S No. T-24 System ID /

Payment Order No.

Bond Details Draw No.

Amount of

Prize Money

Withholding Tax Net Amount

Payable (PKR)

Bank Credit Details PO Delivery

Date Series Serial No. Rate Amount (PKR) FT Number Date

1

2

3

4

5

6

7

8

9

10

Total

Prize money claim of aforementioned prize winning National Prize Bond(s) is admitted / rejected.

Officer Senior Officer A.C.M (PBU) IMU Official D.C.M/C.M. Officer / Sr.

Officer ACM (PBU) IMU Official

C L A I M A N T ’ S A C K N O W L E D G E M E N T F O R O F F I C E U S E O N L Y

Received [please tick () the relevant]: Payment made vide:

⧠ I authorize SBP BSC office to credit the prize money amount as well as face value (if applicable) to my bank account as provided on obverse. ⧠ Bank Credit

⧠ __________ No. of Payment Order(s) for prize money along with face value of Rs. ______________________ (Rupees________________________________________ against __________ prize winning Bond(s) as detailed on obverse).

⧠ Payment Order

⧠ Cash Rs. ________________________ (Rupees_______________________________________________________________________) for prize money and face value (if applicable) against ________________ prize winning bonds.

⧠ Cash

Claimant’s Signature-1 Claimant’s Signature-2 Signature Verified