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Declaration Form

This document certifies that V. Ramakrishna has worked as a Deputy Executive Engineer since 2015 with a salary of Rs. 101,870. It lists his four dependents: wife J.L.K. Pavani, sons V. Sai Dhruva and V. Vishwa, and mother S.A. Manga along with their details. Ramakrishna declares the information is true and understands disciplinary action can occur for listing ineligible dependents. His DDO verifies the information matches office records.

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229 views1 page

Declaration Form

This document certifies that V. Ramakrishna has worked as a Deputy Executive Engineer since 2015 with a salary of Rs. 101,870. It lists his four dependents: wife J.L.K. Pavani, sons V. Sai Dhruva and V. Vishwa, and mother S.A. Manga along with their details. Ramakrishna declares the information is true and understands disciplinary action can occur for listing ineligible dependents. His DDO verifies the information matches office records.

Uploaded by

varanasirk1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

DECLARATION BY THE EMPLOYER

This is to certify that Sri/Smt/Mr/Ms. V.RAMAKRISHNA S/o/ V.S.SHASTRY is working as

DEPUTY EXECUTIVE ENGINEER since 2015 year in the office of Chief Engineer ,CDO, of Department

Irrigation & CAD with a pay grade of Rs 1,01,870/-

The following are the dependent beneficiaries of the concerned employees

S.No Name of the Date of Gender Relationshi Maital Aadhar number


Beneficiary Birth p with status(Married/Un
Employee married/Widow/Wi
dower/Divorce
1. J L K Pavani 22.12.1985 Female Wife Married 295286942125
2. V. SAI 12.06.2012 MALE SON UNMARRIED 954931119006
DHRUVA
3. V.VISHWA 20.12.2015 MALE SON UNMARRIED 385985968561
4. S A MANGA 16.09.1948 FEMALE MOTHER MARRIED 938386794398

Declaration of the Employee

I declare that the above information is true to best of my knowledge and submitting to
Aarogyasri Health Care Trust for issue of Health cards under beneficiary. I am liable for disciplinary
action for declaring ineligible family member if any as Dependents.

Employee Signature

I certified that the above information is verified with office records and found correct

DDO/HOD/Controlling officer Signature with seal

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