ANNEXURE +1 PART -A UFE CERTIFICATE ‘7a be suomitiog by Pensioner / Fanviy Pensioner once @ yas) vertified that | have seen the Pensioner / Fantly Pensioner PRIUITM, ose holaar of PPC, No, ana that ne/ she is alive on this date ‘Spaciman Signature of Pensioner / Family Pensioner / Exgratia beneficlary .. OFFICER Signature of Attosting: Name Office Seal PART -B ADDITIONAL INFORMATION OF PENSIONER / FAMILY PENSIONER / EXGRATIA BENEFICIARY (To be submited by Pansioner/ Family Pensioner / Exgratia beneficiary one - lime only) PPO. No. Name of Bank and Branch ® ‘Name of Pensioner / Family Pensioner: Exgratla beneficiary : 4 Expansion of initial = Date of Birth (with proof for family pensioner) 6 . Type of Pensioner 7 Are you in receipt of Military pension it yes, specify family pension opted 8 Bank Name © Branch Name "FSC Code ‘Bank Account No, Ration Card No.1S. E-mail Addross if available 16. Landline No. if available 1? Mobile No, 18. Blood Group 18 Address with Pin Code District Pin Code Signaturd of Pensioner / Family Pensioner / Exgratia beneficiary a ANNEXURE - It NON - EMPLOYMENT / RE-EMPLOYMENT CERTIFICATE (7o be Submited by Penatone Family Penaloner Expr beneficiary ence a year OR atthe Ue of employe r-employees) |, declare that | hava nat been serving in any capacity either in a State or Central Government or a Governmant Undertaking er a Gevernmant Corporation of an Aulonomeus Body ot a Local Fund oR employed / re-amplayed a the Office Of oo. a nnn inc __ Bhd was In recelpt of the following montnly rates of emoluments during the year ended cons OF during the months of 1 deciare tnat t have ber ‘within the said years 8) Pay inthe Pay Bond b) Grade pay Deamess Alowance 4) Other Allowance (ike HRA/ CCA/ MA tc) Honorarium / Consolidated Pay / Others (Specify) Further that the orders of my re-employment do / do not stipulate my pension belng held In abeyance during the re-employment periog, (OR) { declare tnat | nave not accepted employment under Government eutside India. (OR) | declare that | have accepted employment under a Government outside India after obtaining the previous sancton of the Goverment and none ofthe corklitons attached by the Government has been deviated from without 2btaining previous sanction of the Government, ‘Signature of Pensioner / Family Pensioner! Exgratia beneficiary Neen EEEEEEEEEEEITEEEEEEEN EDEN EIEN ANNEXURE - Ill NON - RE- MARRIAGE / NON - MARRIAGE CERTIFICATE a ve Sutmined by Penaloner Femi Penslonat | Exgraua benaficlary once a jeer OR Inthe evect of remarriage mactags] ‘{Appicable only for Widow / Widower / Daughler/ Son recplent of family pension / Exgratia) I hereby dectare iat | have not married and that | have not been married curing the past year OR I hereby declare that | ave nat re-martied! married and | uncertake to report such as event prompt 12 the Bank concemed. Signature of Pensioner ! Family Pensioner / Exgratia beneficiary a PENSION - INCOME TAX PAN NO Sete i