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PPO. No........
LIFE CERTIFICATE TO BE SUBMITTED BY THE PENSIONER

1. Name of Pensioner/Family Pensioner :

2. PPO No. :
3. Saving Bank A/c No. :
4. Present Address
:……………………………………………………………………..................
…………………………………………………………………………………………
5. Mobile No. of Pensioner/Family Pensioner :
6. Email ID of Pensioner/Family Pensioner: :
DECLARATION

I declare that I have not received any medical allowance from any other
pension authority other than Rubber Board.
I declare that I have received medical allowance from any other pension
authority other than Rubber Board, I furnish the details as enclosure.

Signature of Pensioner/
Family Pensioner

LIFE CERTIFICATE BY AUTHORISED OFFICER

Certified that I have seen the Pensioner (Name)Sri/Smt………………...............

…………………holder of PPO No…………………. & he/she is alive on this date.
His/her saving Account No. is …………………………………………………………

Specimen Signature of Pensioner

Signature of authorized Officer

Place: Name:…………………………………..
Date: Designation:
Seal

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NB: This certificate is to be signed by an Officer of the Rubber Board/Central

Govt./ State Govt. or Manager of a Nationalised Bank.