Anne xure- IV

ANNUAL LIFE CERTIFICATE . .

{To be subm itted by ex-employee/member bene f the
ficiary at the begin nmg 0
financial year)
1. Employee No. :

2. Name of the Ex-employee/ member beneficiary

(in case of deceased employee): G,,, R, "\ • ESW M~ ~<E- DD'!
[The below mentioned Fonn should be signed on
or after 1st of April of every
finan dal year by the Ex-employee/ Member benef
iciary (in case of deceased
employee} 'and A I IESTEll_ by 111,y of the following offici
al(s}:
Bank Branch Mana ger/ ctaletted Officer / Registered
Medical Practitioner I Post
Master I School or College Principal / Class-I Office
r of any Government or Semi
Government or Quasi Government or Government
Undertaking or Public Sector
. Undertaking/GAIL Executive]

"I, ?. \M ,M_ )d/AS k+IA hereby certify that Shr i/~

G, · A. 'I I"" Sw,MU R(D,:Juse/Son/Dau!;jbter/
appeared before me on o Ii 2-D 2..'1
of @,~WI \ bl 1\-N DI ll@ D'./--
personally
and has signed in my presence and his/her
signature is attested below~ I am fully satisfied about
his/her identity".
Dated at ~ ~ ~ l - - = = - - this o9, day of l"anucbj 20"1

~NKL]'-
Counte § ~of

*
'
u d

Mem ber ---- ---" '-- Certifying Authori

{Stamped)
06
01
.;,
0
°' ,o,)
")J)~'-'
~~= -== ==~ ·---- -
0 Y- Le,~
Name: f c- ~,w AA '" SHA
Designation: _l) ~ \ . l ~ 1S"C \~ rro":)e__g
• Add
Offiace ress: U_c,c.., ~Qtl ~\
':J

R5)iu'l-,
Set~ c2.wo. . No__f!t __rte..
~\GY\ a~cD, s: , :51) , • ..A.- "
Contact Number: i2-t tq.4 09o 3,
ID No.: l..\""- ~ \:,

Ex-employee's / Member beneficiary's email ID:

Cs? 1~1f RED 'D'j (i \'
Residential Telephone Number:

4
Mobil e Numb er: _ _ _ _ _9_4-..._9 Oh 3 3 9'6
************