BORANG PERMOHONAN PENTADBIRAN HARTA PUSAKA APPLICATION FORM FOR ESTATE ADMINISTRATION
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1 Untuk Kegunaan Pejabat Sahaja For Office Use Only Harta Pusaka: No Fail : Cawangan : Setem Hasil RM10/- dan dibatalkan BORANG PERMOHONAN PENTADBIRAN HARTA PUSAKA APPLICATION FORM FOR ESTATE ADMINISTRATION *Sila lengkapkan borang ini dengan HURUF BESAR menggunakan pen dakwat hitam / Please complete this form in CAPITAL LETTERS with black ink. *Sila gunakan lampiran tambahan sekiranya perlu / If necessary use additional sheet of paper. 1.0 KETERANGAN PEMOHON / Particulars of Applicant Nama Penuh / Full Name (Seperti Dalam Kad Pengenalan / As stated in NRIC ) K.P. Baru / New NRIC - - K.P. Lama / Polis/Tentera/ Pasport / Old NRIC /Police/ Army/Passport Alamat Surat Menyurat / Correspondence Address Alamat Tetap/ Permanent Address No Tel. Rumah / Home Tel Tel Pejabat / Office Tel. Tel. Bimbit / Handphone E-mel / Perhubungan Persaudaraan dengan Si Mati / Relationship with the deceased Suami / Husband Isteri/ Wife Bapa / Father Ibu / Mother Anak / Child Lain-lain / Others (Sila nyatakan / Please specify) 2.0 KETERANGAN MENGENAI SIMATI / Particulars of Deceased s Nama Penuh / Full Name (Seperti Dalam Sijil Mati/ As stated in Death Certificate) Sijil Kematian/ Death Certificate Tarikh Meninggal Dunia/ Date of Death Sebab kematian / Cause of death Muflis / Bankrupt Biasa/ Natural Ya / Yes Kemalangan/ Accident No/No Pendaftaran Wasiat / Will Registration 1/5
2 3.0 KETERANGAN MENGENAI HARTA / Particulars of Assets 3.1 Harta Tak Alih ( Contoh : Tanah/Rumah) / Immovable Assets (e.g : Land / House) Jenis Hakmilik / Type of Title Hakmilik / Title Lot / Lot Mukim/Bandar / Area/ City Daerah/Negeri / District/State Bahagian / Share 3.2 Harta Alih ( Contoh : Tunai/Akaun Bank/Saham/ KWSP/ Kenderaan/ Insuran) / Movable Assets (e.g : Cash/ Bank Account/ Share/ EPF/ Vehicle/ Insurance) Jenis Harta/ Asset Type Akaun/ Ahli/ Pendaftaran/ Dan Lain-lain / Account / Membership / Registration / etc. 2/5
3 4.0 KETERANGAN MENGENAI HUTANG SI MATI (Termasuk Belanja Kematian) / Particulars of Deceased s Liabilities (Including Funeral Expenses) Jenis Hutang / Type of Liability Nama dan Alamat Pemiutang / Creditor s Name & Address 5.0 KETERANGAN MENGENAI PENGHUTANG / Particulars of Debtors Jenis Hutang / Type of Liability Nama dan Alamat Penghutang / Debtor s Name & Address 6.0 KETERANGAN MENGENAI WARIS-WARIS / Particulars of Beneficiaries Sila tandakan( ) pada kotak jika nama waris tersenarai dalam wasiat / Please tick ( ) at the box if beneficiaries appear at will. 3/5
4 * Sila guna lampiran jika perlu. 7.0 KETERANGAN MENGENAI PENJAGA (Bagi kanak-kanak di bawah umur 18 tahun / Orang kurang upaya) / Particulars of Guardian (For minors under 18 years / incapacitated person) Nama Penjaga / Guardian s Name - - 4/5
5 Alamat Surat Menyurat / Correspondence Address No Tel. Rumah / Home Tel Tel. Bimbit / Handphone Tel Pejabat / Office Tel. E-mel / Perhubungan Persaudaraan dengan kanak-kanak/ OKU / Relationship with minor Incapacitated person Bapa / Father Ibu/ Mother Dengan Perintah Mahkamah / Court Order Lain-lain / Others (Sila nyatakan / Please specify) 8.0 AKTA PERLINDUNGAN DATA PERIBADI 2010 / The Personal Data Protection Act 2010 Dengan menyempurnakan borang ini anda membenarkan maklumat peribadi anda untuk digunakan oleh AmanahRaya dan/atau anak syarikatnya untuk memberikan anda perkhidmatan AmanahRaya dan/atau anak syarikatnya yang bersesuaian dengan anda. Maklumat peribadi yang diberikan oleh anda akan digunakan untuk pentadbiran dan pengurusan perkhidmatan yang diberikan kepada anda. Maklumat peribadi anda boleh digunakan untuk memberi anda maklumat lanjut mengenai produk dan perkhidmatan yang sesuai dengan anda daripada AmanahRaya dan / atau anak syarikatnya Maklumat tersebut adalah sulit dan persendirian dan tidak akan dikemukakan kepada pihak ketiga tanpa kebenaran anda. Semua maklumat yang diberikan oleh anda dalam borang ini adalah tepat, lengkap dan terkini. Jika anda ingin mengemaskini maklumat peribadi anda, sila hubungi kami di talian / In completing this form you consent for the personal information contained in this form to be used for the purposes of providing you with the relevant services of AmanahRaya and/or its subsidiaries. The personal information provided by you will also be used to administer and manage the service that is provided to you. The personal information may be used to provide you with further information about AmanahRaya and/or its subsidiaries, its products and services that may be of interest to you. The said information will be kept as private and confidential and will not be disclosed to third parties without your consent. All personal information provided by you in this form is accurate, complete and up-to-date. If you require for your personal information to be updated or corrected please contact us at / AKUAN / Declaration Tandatangan Pemohon / Signature Of Applicant SAYA, dengan sesungguhnya dan sebenarnya mengaku bahawa tuntutan pusaka ini belum pernah dibuat dan segala keterangan yang tersebut di atas adalah benar mengikut pengetahuan saya sendiri dan saya membuat akuan ini dengan kepercayaan bahawa apa-apa yang tersebut di dalamnya adalah benar, serta menurut Akta Akuan Berkanun ( I, do solemnly and sincerely declare that there are no other petition filed and I make this solemn declaration conscientously believing the same to be true, and by virtue of the provisions of the Statutory Declaration Act 1960). Diperbuat dan dengan sebenarnya diakui oleh yang tersebut namanya di atas iaitu... di... di Negeri... pada... haribulan (Subscribed and solemnly declared by the abovenamed Tandatangan Pemohon /... Signature of Applicant at... In the State of... This... day of...) Di hadapan saya, Hakim Mahkamah Sesyen/ Majistret/ Pesuruhjaya Sumpah * Sila COP JURAT di Pesuruhjaya Sumpah berkenaan sekiranya tandatangan tuan/puan dalam Bahasa CINA / TAMIL / JAWI COP IBU JARI. Sebarang lampiran tambahan perlu diikrarkan dlhadapan Pesuruhjaya Sumpah. 5/5
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