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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 :
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.
Khua / Veng : ____________________ Name : ______________ P.O. : ____________________ PPO NO : ______________ Phone NO. : ____________________ A/C No. : ______________
Date : __________
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