Name of the Bank……………………………….............Branch…………………………..
Bank Account No……………………………………….Treasury File No………………..
Nature of Pension:[State/Teacher/Panchayet/Other State/Money Order]
Pension……………………………………………………………………………………….
(As mentioned in the Computerized Monthly Pension Bills)
ANNEXURE-VI I.D.No__________
(CERTIFICATE TO BE SUBMITTED BY PENSIONER)
[VIDE RULE 5 (3)]
I. LIFE CERTIFICATE:
Certified that I have seen the Pensioner ……………………………………………………….
(Name of the Pensioner)
holder of Pension Payment Order No……………………. and A/C No………………………
Of…………………………………………………...Bank and that he/she is alive on this date.
Place: Name………………………………………………………..
Signature & Designation of the …………………………….
Authorized Officer …………………………….
Date: Seal:
II. NON-EMPLOYMENT CERTIFICATE
* I declare that I have not received any remuneration for serving in any capacity in an
establishment of the Central Government or a State Government or Government undertaking or from
a local fund during the period from November to October,200…………….
* I declare that I have been employed /re- employed in the office of
……………….………………and was in receipt of the following emoluments during the period.
* I declare that I have accepted commercial employment after obtaining/without
obtaining sanction of the Government.$
* I declare that I have/have not accepted any employment under any Government
outside India after obtaining/without obtaining sanction of the Government.
Place:……………………….. Signature………………………………………….
Date…………………..…….. Name of the pensioner……………………………
* Delete whichever is not applicable Pension Payment Order No………………………
$
To be specified
ANNEXURE-VII
[VIDE RULE 5 (3) & T.R. 4.186 (4)]
YEARLY DECLARATION OF PENSIONERS WHOSE PENSIONS ARE TERMINABLE ON THEIR MARRIAGE OR
REMARRIAGE (THIS CERTIFICATE IS TO BE SUBMITTED IN NOVEMBER EVERY YEAR)
Pension Payment Order No…………………………………………………………………………
I hereby declare that I am not married and that I have not been married during the last one year.
Or
I hereby declare that I have not been remarried during the last one year ending on 31st
October,20……..and I undertake to report such an event promptly to the Treasury/Bank
Signature……………………………………………………
Date:………………….. Widower/Widow/daughter of late………………………….
______________________________________________________________________________
(To be signed by an Authorized Officer)
I certify to the best of my knowledge and belief that the above declaration is correct.
Date:………………….. Signature………………………………………
Designation……………………………………
4.171(2) A pensioner of any description shall be required to furnish a life certificate once a year in the month of November in the
form as mentioned in Annexure VI of part B of Appendix 15.a) Officers of the RBI and Public Sector Banks, b)Any Group-A
employee of the State or Gazetted Officer of the Central Govt, c) Registrar or Sub-Registrar, d) Police Officer not below the rank
of a Sub-Inspector in charge of a Police Station, e) Post Master/Departmental Sub-Postmaster/Inspector of Post Offices, f) Asstt.
Inspector or Sub-Inspector of Schools, g) Officer of the Subsidiary Bank of the State Bank or any Bank included to the RBI (Act
1934), h) Head of a Gram Panchyet /Panchayet Samity / Zilla Parishad, i) Head of any Non-Govt School/ College. j) Any
Registered Medical Practitioner,k) Any M.P. or MLA/ Councillor / Chairman of a Municipal Corporation or Municipality, l)
Managing Director /Director of a State or Central Public Sector undertaking.
_______________________________________________________________________________________________________
