STATE BANK OF INDIA

CERTIFICATE TO BE SUBMITTED BY PENSIONER A) LIFE CERTIFICATE Certified that I have seen the pensioner ________________________________________ (Name of pensioner), holder of Pension Payment Order No. ____________________ and he / she is alive on this date. Savings Bank A/c No. Specimen Signature of pensioner __________________________ Place: Date Seal Name & Designation of Authorised Officer

B) NON-EMPLOYMENT CERTIFICATE # I declare that I have not received any remuneration for serving in any capacity in an establishment of Central Government or a State Government or a Government Undertaking or from a Local Fund during the period November ____ to October _____. # 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 not accepted any employment under any Government outside India, after obtaining / without obtaining sanction of the EPF organization (to be furnished by Class I officer only) # Delete whichever is not applicable. Place: Signature_________________________ Name of Pensioner _________________ PPO No.

C) CERTIFICATE OF RE-MARRIAGE / NON-MARRIAGE I hereby declare that I am not married / have not married during the past twelve months. Signature__________________ Name of Pensioner _______________ PPO No. -----------------------------------------------------------------------------------------------------I certify to the best of my knowledge and belief that the above declaration is correct. Place: Signature of a responsible officer/well known person Name: ________________________________ Designation:_______________________________

Place: Date: