CERTIFICATE TO BE SUBMITTED BY PENSIONER

I. SELF PARTICULARS (to be completed by the pensioner)
Name of the pensioner________________________ date of birth_____________________
Father’s Name_______________________ Mother’s Name___________________________

II. LIFE CERTIFICATE

Certified that I have seen the pensioner _________________________________________
_________________ (Name of the pensioner) holder of pension payment.
Order No_________________ and that he is alive on this date.
Signature /Thumb impression of pensioner
Place: Name_________________________________________
Designation of authorized Officer
Date: Seal
III. CERTIFICATE OF NON RE-MARRIAGE
I hereby declare that I have not been re-married and I undertake to report such an event promptly to the pension Disbursing Authority / Bank
Signature____________________________________
Place: Name of the pensioner__________________________
Date: P.P.O. No. ___________________________________
I certify to the best of my knowledge and belief that the above declaration is correct
Signature of a responsible officer
Place: or a well known person__________________________
Date: Name: _______________________________________
Designation: __________________________________