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Parental Income Self-Declaration Form

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nayakbharath181
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116 views1 page

Parental Income Self-Declaration Form

Check

Uploaded by

nayakbharath181
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Name: Date :

Insurance No:
Address:
State:
Mail Id:
Phone No:

To Whom It May Concern,

Subject: Self Declaration of Parental Income

I, _____________________, Insurance No ______________________, solemnly declare the


following:

1. That my parents' combined monthly income is less than Rs.9000 (Nine Thousand
Rupees) per month.
2. In the event that it is discovered that the aforementioned declaration is untrue or inaccurate, I
undertake full responsibility for any and all medical expenses incurred by my parents, without any
recourse to external financial assistance.
3. It is also understood that if at any point in time my parents' income were to exceed Rs. 9000/-per
month, they would be abstained from receiving medical treatment thereafter.
4. I understand the gravity of this declaration and affirm that the information provided herein is true
and correct to the best of my knowledge.
5. l acknowledge that any false statements made in this declaration may result in legal
consequences.

Please consider this declaration as a true statement made by me, and I am willing to provide further
clarification or documentation if required.

Thank you for your attention to this matter.

Yours Sincerely,

Name:

Signature:

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