PROFORMA OF AFFIDAVIT FOR OBTAINING SURVIVING MEMBER

CERTIFICATE

I Smt. ____________________ w/o _______________ R/o ____________ do hereby

solemnly affirm and declare as under:-

1. That Sh. ____________________ S/o ___________________ expired at

______________ on _____________ and death was registered with MCD. Death
Certificate No. _______________ dated ______________ is attached.

2. That after the death of my husband Sh. _______________________, the

following are the survival members in the family.

Sl.No. Name Age Retation with deceased

1.
2.
3.
4.
5.

3. That the none other than mentioned above is the survival member in the family.

4. That survival member certificate is required for submission in the Office of

___________________________.

5. That this is my true statement.

Deponent

Verification: Verified at Delhi, this _____________ day ___________ that the contents
of the affidavit are true & correct to the best of my knowledge and belief and nothing has
been concealed therein.
Deponent