CERTIFICATE

1. Certified that I am occupying rental house and paying monthly rent of Rs .………….….(Rupees ……
………………………………..) per month.
2. Certified that I am paying a sum of Rs …………………….. (Rupees …………………………
… …………….) towards LIC premium and Policies are kept alive. Policy No…
……………..
3 .Certified that the Medical allowance paid for meeting cost of medical expended are fully incurred by me for
the same.
4. Certified that all the figures and particulars given above are true to the best of my knowledge and belief..

Signature of the individual

Statement showing the pay and allowances Drawn by ……………………….for the year.2000-01
Month Pay D.A Spl HRA MA GROSS GPF FBF SBF HF TOTAL
& Year .pay
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Arrears
pongal

Total

Particulars of LIC Premium/PLI

Policy Number Name of the Nature of policy Amount insured Amount of premium
company Per annum

Particulars of NSC/NSS/UTI/etc
POST OFFICE ISSUE DATE NO.. NSC/NSS NUMBER AMOUNT

Signature of the
Drawing Officer