Pass Port size Photo of the Pensioner

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Nature of Pension Name of Pensioner S/o, W/o, D/o, Photo of Date of Birth P.P.O.No. Name of Bank Bank Account No Re-employment/employment particulars Name of the Office Date of employment /employment Tenure Total emoluments drawing Certified that he/she is not drawing any other Pension Certified that he/she is drawing other Pension Through P.P.O.No. Remarriage particulars Date of remarriage Name of the spouse Present Residential Address Phone No.

Certified that I have seen the above pensioner as on ------------------- and he/she is alive on this date. The particulars furnished above are true to the best of my knowledge.

Signed before me

Left hand thumb impresion Of the pensioner OR (Signature of the Pensioner)

Signature of the Treasury Officer STO/ATO/APPO Name and Seal Signature of the Gazetted Officer.

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