INDEMNITY FORM

From : Name : ______________________________ Place : _______________

Account No.: ________________________ Date : _________________

To
The Manager,
Citibank, N.A.

 Ahmedabad  Aurangabad  Bangalore  Bhubaneshwar  Chandigarh

 Chennai  Coimbatore  Delhi  Faridabad  Gurgaon
 Hyderabad  Indore  Jaipur  Kochi  Kolkata
 Lucknow  Ludhiana  Mumbai  Noida  Pune
 Surat  Vadodara

Dear Sir,

Re : Demand Draft/Manager’s Check/FDR/ATM Card

No. : ......................................................................
Version 1.1

Date : .....................................................................

Amount : ...............................................................

Mat Date : .............................................................

In the name of : ...................................................

We hereby declare that the above instrument issued by Citibank in my/our favour, particulars of which are
stated above has been lost/misplaced by us/has not been received by us.

In consideration of the Branch to issue to me fresh instrument in lieu of the above mentioned on at my
request, I hereby agree, at all times to indemnify and keep harmless Citibank against all claims, demands,
suits, losses, damages etc., of whatsoever nature made and all actions and proceedings taken against the
said bank by any party arising from such fresh issuance/lost or misplaced DD/MC/ATM Card.

I further declare that I have not pledged or deposited or otherwise disposed off the said instrument or
misused the same in any manner whatsoever, and I hereby undertake to deliver to the bank the original
instrument /receipt whenever found.

Yours sincerely

Signature
(The form should be signed after all details are filled.)

Name:
CV 12/11