..-:,........ !... r r.. i r..

and S' B'A/e N0' of Bank

Branch ,........r.,..o....,..G....r.oo...oo"".... and that He/Shg is alive on

thls datg ....o.'. "'tt " " " t t't""t " t'o "t '6 t' t '

Signature of the Pensioner

Signature of the Gazetted officer /
Bank Manager with seai

ldeclarethatlhaveaccepted/notacceptedanyemployment

I declare that I have been employed/re-employed in the olfice of the .....""""'r"1":';""""""

o' l tt" t l t o tt " t r t
W.e.f.... a....'..t " " " " "t " " " "' "

Signature of the Pensioner

Attestation of Gazetted officer
with seat

:CERTTFICATE OF NON.REMARRIAGE
ilT .

I declare that I have been rnarried / re-married on

I dectare that I have nct been married / rernag"ried

Signature of the Pensioner

Att*stati*r: of Gaxetted *ffieer
I