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 ........................................................... (N arne 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 or
Place: a well-known person _______________ _
Date: Name: -------------------------------------------
Designation ____________________ _
D:\VYAS\CERTIFICATE TO BE SUBMITTED BY PENSIONER.doc