LIFE  CERTIFICATE

 

Certified that I have seen the pensioner __________________________ holder of pension Payment Order No.  _________________________  and that he / she is alive on this date.

 

 

Signature of Pensioner                                            Signature of Authorised Officer

 

Date :                                                                       Date :

 

 

FORM OF CERTIFICATE OF NON-EMPLOYMENT / RE-EMPLOYMENT

 

            I  declare that I am not serving in any capacity either in a Govt. Department/Office/ Company/Corporation/Autonomous Body or Society of Central/State/U.T/Local Body. I declare that I am not serving in any capacity either in a Govt. Department/ Office/Company/Corporation/Autonomous Body or Society of Central/State/U.T/ Local Body.

 

O R

 

            I declare that I have been employed / re-employed in the Officer of _________________  w.e.f ___________  which is a partly / fully financed by Central / State/U.T / Local Body.

 

 

DECLARATION OF NON-MARRIAGE/RE-MARRIAGE

            I hereby declare that I am not married / re-married.

 

OR

 

            I  have got married/re-married on _____________  with _________________  (Name of spouse and address to be mentioned)

            I hereby declare and undertake that I am entitled to Medical Facilities under CGHS or Other similar Scheme/Armed Forces Hospital/M.I. Rooms but I am residing in an area where no such medical facilities are available.

           

            I certify to the best of my knowledge and belief that the above declaration is correct.

 

 

FULL ADDRESS OF THE PENSIONER                         Signature of  Pensioner

 

Khua / Veng  : ____________________                        Name     :  ______________

P.O.                 : ____________________                         PPO NO : ______________

Phone  NO.    : ____________________                         A/C  No. : ______________

 

Date : __________