Affidavit/Declaration by the couple
undergoing Donor Egg IVF
We, 1. Mrs. ASWINI, aged 39 Years, W/o. Mr.KARTHIK (Aadhaar Card
No. 2716 8830 2518), 2. Mr.KARTHIK S/o. Muthukumaran, aged 42
Years, (Aadhaar Card No. 3224 4938 6863), both are residing at Plot No
77, F3, 3rd Main Road, Ramamoorthy Avenue, Kolapakkam, Chennai-
600125, do hereby solemnly affirm and depose as under:
That we are taking IVF treatment with donor eggs at ISWARYA HEALTH
PRIVATE LIMITED, No:13, 1st Main Rd, Opposite Sangeetha Hotel,
Kasturba Nagar, Adyar, Chennai, Tamil Nadu 600020.
This declaration / guarantee /affidavit is prepared as required by Rule
12 (ii) of the ART Act 2021. We undertake to provide a guarantee of
compensation for specified loss, damage, complication or death of
oocyte donor during the process of oocyte retrieval. We have also
been informed that as per Section–22(1) (b) of ART (Regulation) act,
2021 - (b) an insurance coverage of such amount as may be
prescribed for a period of 12 months in favor of the oocyte donor by
the commissioning couple or woman from an insurance company or
an agent recognized by the IRDA established under the provisions of
the IRDA Act, 1999. We hereby also agree to take the necessary
insurance coverage favoring the Oocyte Donor.
We hereby understand that the clinics and banks shall ensure that
information about the commissioning couple, woman and donor shall
be kept confidential and the information about treatment shall not be
disclosed to anyone except to the data base to be maintained by the
National Registry.
We undertake to indemnify and keep the ART BANK and Clinic
Indemnified, if any statement or fact stated by us is incorrectorfalse.
We have read over the contents of the affidavit and after fully
understanding the contents, we have executed this affidavit out of
our own freewill.
Signed at Chennai at this 07th day of Signature
August 2025
Wife Name: Mrs. ASWINI.T
Husband Name: Mr. KARTHIK.M
Counselor/Witness Name: VEERA
SAKTHI.V
Verified/Notarizedby
