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DIVISIONAL OFFICE FORM OF RECEIPT FOR THE SURRENDER VALUE OF POLICY NO. -------------------------------------------------------------------------------------------------------------------------------On
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of its shares to me/We or have assigned its shares to me/We or have any interest or right in their shares.This declaration is to be binding on me/We.I/ We hereby hereby declare under penalty of perjury under Section 18 of the Evidence Act, 1960 that On the Life of 1/10/12 dated 23/7/12 the above mentioned person has not been a Party to the case.I/ We hereby declare under penalty of perjury under Section 18 of the Evidence Act, 1960 that From 9/6/12 The above mentioned person has not been a Party to the case.I/ We hereby declare under penalty of perjury under Section 18 of the Evidence Act, 1960 that I/we are not a Party to the application dated 9/1/12 and the following documents are not required to be filed on this Application:(1) the copy of the Life Insurance Certificate which I/We have received from the Corporation of Insurance;(2) the Form submitted and signed by the Life Insurance Agent as referred to in paragraph I (a) (1) or (2) of Section III.S.1 of the Rules of the Company for registration of the shareholding, (3) the Form submitted and signed by all other employees and agents as referred to in Section I.B.1, (4) the Form submitted and signed by any other Company Officer in connection with the transfer of shares referred to in Section IV., (5) the Form submitted and signed by any other Officer in connection with purchase or sale of the shares referred to in Section V of the Rules of the Company; (6) the Form submitted and signed by any Trustee, Director or Manager of the Company in connection with appointment or renewal (or the date on which such renewal or appointment shall become effective) of any Director, or as referred to in Section II.D./V.D.2, or as referred to in Section III.S.I.2 of the Rules of the Company; and (7) the Form submitted and signed by such other person in connection with any claim for payment or distribution made under this Chapter of Life Insurance.I/ We hereby declare under penalty of perjury under Section 18 of the Evidence Act, 1960 that in respect of the foregoing Statement, I have not received from any other person any evidence to support any of the matters set out in the foregoing Statement.The Declaration shall remain binding and irrevocable notwithstanding that some of the above mentioned documents are filed, filed by the Party or parties against the
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