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(Name of The Bank and Address With IFS Code) : Life Certificate

The document is a Life Certificate for pensioners, requiring personal details and verification by a bank manager to confirm the pensioner's status as alive. It includes sections for bank account certification and a declaration for family pensioners regarding remarriage. Additionally, there is a form for medical allowance indicating whether the pensioner is availing medical facilities.

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yashika.ydv.hr
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26 views4 pages

(Name of The Bank and Address With IFS Code) : Life Certificate

The document is a Life Certificate for pensioners, requiring personal details and verification by a bank manager to confirm the pensioner's status as alive. It includes sections for bank account certification and a declaration for family pensioners regarding remarriage. Additionally, there is a form for medical allowance indicating whether the pensioner is availing medical facilities.

Uploaded by

yashika.ydv.hr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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(Outsider Pensioners)

LIFE CERTIFICATE

Latest Photograph of
pensioner/family
1. Shri/Smt_______________________________________________ pensioner
Attested by Municipal
Pensioner/Family Pensioner of Sainik School Kapurthala presented Councilor/Village
Surpuch/Officer Gram
himself/herself before me i.e The Manager of Panchayat/ Bank
Manager with office seal
the______________________________________

__________________________________________from where the above

(Name of the Bank and address with IFS Code) referred Pensioner/Family
Pensioner is drawing pension/family pension.

2. The said Pensioner/Family Pensioner has signed or affixed his/her LTI/RTI before me
(Please tick whichever is applicable) on _______________ (date to be mentioned). As such I certify
that the above referred Pensioner/Family Pensioner is ALIVE AS ON DATE.

…………………………………

(Signature of Pensioner)

Name :____________________

Address: ___________________

___________________________

Pin Code :__________________

Tele/Mobile No______________

E-mail ID (if any)_______________________

……………………………………………
(Verified by the Bank Manager with Official Seal)
CERTIFICATE REGARDING BANK ACCOUNT

1. Certified that Sh/Smt_______________________________________ is operating Saving

Bank Account Number__________________________________________ in this bank. This

account is operated single handed. This is neither a joint nor either or survivor account.

2. The IFSC of the bank is …………………………

…………………………………
Place : Signature of Bank Manager
Date : With Bank Seal
(For Family Pensioner only)
(Certificate of Re- marriage / No marriage)

I, hereby declare that I have not been re-married after the death of my husband late

Sh ________________________________________.

Place: …………………………………

Date : (Signature of Family Pensioner)

Name :____________________

Address: ___________________

___________________________

Pin Code :__________________

Tele/Mobile No______________

Witness 1 :-

Name :____________________

Address: ___________________

___________________________

Pin Code :__________________

Tele/Mobile No______________

Witness 2 :-

Name :____________________

Address: ___________________

___________________________

Pin Code :__________________

Tele/Mobile No______________
FORM FOR MEDICAL ALLOWANCE

I hereby declare and undertake that I am availing / Not availing the Medical facilities under
CGHS or other similar scheme/ Armed Forces Hospitals/MI Rooms.

My residential address is: Village/ Mohalla ……………………….……… P.O.

………………………………… Distt. …………………………Pin………………

________________________________
Signature/Thumb impression of pensioner
Name …………………………………

PPO No. ………………………………

S.B.A/C/H.O. No. ………………

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