10. "1 waar ort afer fafa aot eawantott COAL MINES PROVIDENT FUND ORGANISATION are SRA AER, Pera HATH SHR (MINISTRY OF COAL, GOVERNMENT OF INDIA) tet Pacer tems ar aT Pensioner's Name Sesto are eee Adhaar No. of Pensioner fear ar arr Father's Name sna ear are (eet STAT HPT A STA) —_ SS Spouse Name (As appearing in pension claim form) Sufi ar STU AEAT [ Spouse Adhaar No. wurafr. Gat F CMPF A/c No. Stu aprane arter @. eae Pension Payment Order No. Date ahora, eater arate, es, Gert etpisy oritarth ar feat details of Pension Sanctioning Authority. CMPF Regione! Office, Region waa a ore a. Saving Bank A/c No aera dar rear Sree BS Paying Bank Branch IFSC Code Gerasiatt a Ataréer eaw/ Mob. No. of the Pensioner| defer target aw Alternative Mob. No. $1 Email id: gg aR ana Ce cece a is TE) seonfer Fave rer & ARs a after & athe EAR soaToT a wT A reer Gece wT laraVeThaT rier Prener aa weTreét GI (Certificate that | am alive and putting my signature/LTURTI as token of proof) wearaa after & eecTey Seri ar eemTeTVatarenigen srjgr ferent Verifying official Signature Signature/LTURTI of Pensioner aire (Name):- ‘art (Name), ‘"q (Post) adem Tat (Address) fate (Date) :2areidare seroma) papi a ary ware i (NON REMARRIAGE CERTIFICATE OF SON/DOUGHTER) 13 Se cere cbse eran fh AR wale afi rar ate A tet re ar ear deer Rae softartver at 2 or aay tema & (Reavy & ara | hereby declare that | have not fe-martied and in undertake to report such an event Promptly to th Pension Disbursing Authoriy/Bank (in case of son) 2, Ha 25 ot Sh airy area at (qa a Aree Hy) | have not attain the age of 25 years (in case of son) SA Rear 6 fear ate HA 26 a arg arr fh AYE (QE Te a) | have not married and I have not attained the age of 25 years (in case of daughter) A sree ecard Raeerar & srener aera & Pe sete cheer EY BI (" cently to the best of my knowledge and belief that the above declaration is correct) Seeit ar remenvanigr fen (SignatureThumb impression of pensioner Fa (Place) eats (Date) : ads ate H Gere serve des eran sta Pra SMe] To be submitted in pension paying Bank Branch only in the Month of November every year for onward transmission to Nodal Banks after verification of Signaturethum® impression of the pensioner by the paying bank.) ate (Note) : + Seoturest & orgie B RG sect te Preere dee (ent ach ant aren) a aah ae eet Patent urd wh aga rar (Sef ar sate area) 3 aRafeier aarti Pensioner’s are requested to consult éisbursing bank branch (Paying Branch) to convert the Existing Account into Joint Account (former or Survivor mode) . Som ROTO ST NSE oe ere ed SMA RT se SF UA a NANT a (nM STS STATOR) ora Asa saAT ref I Pensioner & Spouse identity proof & address proof (Aadhasr Card/Address proof) required at the time of submission of the certificate