Indian Institute of Technology, Kharagpur-721302

CERTIFICATE TO BE SUBMITTED BY PENSIONER/ FAMILY PENSIONER
I.

LIFE CERTIFICATE **

Certified that I have seen the pensioner Sri/ Smt
………………………………………………………………………
………………….. holder of pension payment order No.
………………………………………. and that he/she alive on this date.

Place ……………………….
…………………………………………………
Date ………………………..
Officer (with Seal)

Name
Designation of the authorized

**It is to be signed by the Gazetted officer of the Central or State
Government /
A wellknown and trustworthy person / Officer of SBI or any
Nationalised Bank

II.

NON EMPLOYMMENT /RE_EMPLOYMENT CERTIFICATE

I declare that I have not been serving in any capacity either in a Govt.
Deptt./Office, Company,
Corporation, Autonomous Body or Society of Central or State Govt. or Union
Territory or a Local Fund during the year ended November 2009
I declare that I have been employed /re-employed in the office
……………………….. which is a part of / financed by ………………………………
Govt. and was in receipt of the following monthly rates of emoluments during
the year ended November 2009 or during the month ………………………………
falling within the said year.
Pay ……………………………………………………….. Spl.
Pay……………………………………………………………………..
Allowances
…………………………………………………………………………………………..
(Including DA, ADA etc)
Furthermore, that orders of my re-employment stipulate or do not stipulate
my pension being held in abeyance during the re-employment period.

Signatur e of the pensioner Name of the pensioner ……………………………………………………………………………………………………… ……….. Full Address of the Bank……………………………………………………………………………………………… ………………. ……………………………………………………………………………………………………… ………………. With it Branch Code……………………………………………………………………………………………… …………………….. Pension Code No.. ……………………………………………….. SARIT NANDI POST 61 KARAYA ROAD. ______________________________________________________________________________ To BOOK CS 141090 Sri / Smt. Pension A/C No………………………………………………………………………………………………… …………………………. CALCUTTA-19 .Date……………………..

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