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Заявление на выплату возмещения по застрахованным вкладам

Для получения страхового возмещения по вкладам в банке-агенте, уполномоченном Агентством по страхованию вкладов, вначале пишется следующее заявление, а к нему прилагаются все необходимые документы, подтверждающие Ваши клиентские отношения с банком, у которого была отозвана лицензия:
 
Приложение 1
к Порядку выплаты возмещения по вкладам
от « 3 » августа 2006 г. (протокол № 46)
в редакции решений Правления Агентства
от 13.03.2008 (протокол №12),
от 14.02.2011 (протокол №11)

 

 

В государственную корпорацию

«Агентство по страхованию вкладов»

 

 

ЗАЯВЛЕНИЕ

о выплате возмещения по вкладам

________________________________________________________________________

наименование банка-участника системы страхования вкладов

_______________________________________________________________________

фамилия, имя, отчество заявителя

Число, месяц, год рождения "___” __________________ ______ года

Документ, удостоверяющий личность ____________________________________________________

                                                                               вид документа: паспорт или заменяющий его документ

серия ______________номер ________________          выдан "____” _________________ _____ года

_______________________________________________________________________

наименование органа, выдавшего документ

Адрес для почтовых уведомлений _______________________________________________________

почтовый индекс, страна (для международных почтовых уведомлений),

_________________________________________________________________________

республика (край, область, район), населенный пункт, улица, дом, строение, корпус, квартира

Контактный телефон __________________________________________________________________

Прошу выплатить сумму страхового возмещения в размере, указанном в реестре обязательств банка перед вкладчиками.

Выплату возмещения прошу осуществить:

 

Наличными денежными средствами [1]

 

Путем перечисления на счет в банке

Выбранный вариант отметить любым знаком *, х, v.

 

Банковские реквизиты

(для перечисления денежных средств безналичным путем)

________________________________________________________________________

наименование кредитной организации, в которой открыт счет

 

БИК банка

 

 

 

 

 

 

 

 

 

 

ИНН банка

 

 

 

 

 

 

 

 

 

 

 

Корреспондентский счет банка

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Расчетный счет филиала банка (при наличии информации)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Лицевой счет получателя

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ИНН получателя

 

 

 

 

 

 

 

 

 

 

 

 

(заполняется при наличии информации)

 

Фамилия, имя, отчество получателя_________________________________________

Дополнительная информация[2]___________________________________________

 

 _____________________________      подпись

 

 

                               "_____” _______________  _____года

                                                                                                                             дата подписания заявления

 

 

 

 

 [1] Выплата возмещения по вкладам наличными денежными средствами через кассу Агентства (банка-агента в случае его привлечения к приему заявлений и осуществлению выплат) осуществляется только в случае личного обращения в Агентство (банк-агент) с заявлением о выплате возмещения по вкладам.
Выплата возмещения по вкладам наличными денежными средствами путем почтового перевода осуществляется вкладчикам банка, проживающим вне населенных пунктов, где расположены подразделения банка–агента, указанные в информационном сообщении Агентства о месте, времени, форме и порядке приема заявлений о выплате возмещения по вкладам, размещенном на его сайте (www.asv.org.ru) и опубликованном им в печатном органе по месту нахождения банка.
К заявлению должна быть приложена копия документа, удостоверяющего личность заявителя. В  случае, если сумма страхового возмещения составляет 1 000 (Одну тысячу) и более рублей, подпись на заявлении о выплате возмещения по вкладам, направляемом по почте, должна быть нотариально удостоверена.  

 [2] Данный раздел заполняется в случае: 1)  замены документа, удостоверяющего личность вкладчика, по которому с банком заключен договор банковского вклада (счета); 2) предъявления заявления о выплате возмещения по вкладам лицом, не являющимся вкладчиком банка (например, его представителем).
В первом случае в составе дополнительной информации указываются:
- реквизиты документа, удостоверяющего личность вкладчика, по которому с банком заключен договор банковского вклада (счета);
Во втором случае указываются:
- ФИО вкладчика, интересы которого представляет заявитель, реквизиты документа, удостоверяющего личность вкладчика, по которому с банком заключен договор банковского вклада (счета) (с обязательным приложением оригиналов документов или их нотариально заверенных копий, подтверждающих право заявителя на обращение за выплатой страхового возмещения). Документы, представленные таким заявителем, должны содержать сведения о реквизитах документа, удостоверяющего личность вкладчика.

 

Можно этот бланк скачать прямо сейчас.

Заявление о выплате возмещения по вкладам [51 Kb] (cкачиваний: 1719)


Автор: Правовик от 18-06-2014, 22:14

5 не понравилось

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