CONSULATE GENERAL OF INDIA

201- 325 Howe Street

Vancouver, B.C. Canada V6C IZ7
Phone: 604-662-8811
Fax: 604-609-2031
Website: www.cgivancouver.gov.in
Email: indiavisa@telus.net

No: Date:
Life Certificate

This is to certify that I have seen the pensioner, whose details are given below and that he/she is
alive on this date. He/she has signed/ affixed thumb impression in my presence.

S. No. Description Details

1. Name as in passport/ OCI card/ pension
order
2. Date/place of birth
3. Nationality
4. Father/ Husband’s name
5. Address in Canada
6. Phone number (landline)
7. Phone number (mobile)
8. Email ID
Country:
Number:
9. Passport particulars Date of issue:
Place of issue:
Valid till:
10. Pension payment order/ book number
11. Signature/ thumb impression of the
applicant
12. Place of issue of this certificate

Signature/stamp of authorised person

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Acknowledgement

Life Certificate of Pensioner, Shri/Smt/ Ms ______________________________ holder of pension

payment order no. _________________________________ has been received.

Signature/name/stamp of the receiving bank/branch