A F F I D A V I T
I
Smt. Anju Wife of ___________ Late Havildar ___________of Signals
Regiment solemnly affirm and declare as follows:-
1. That I am drawing pension vide PCDA
Pension Payment Order No S/017862/2008(Army) dated 11 Mar 2008and
S/CORR/217451/2009(Army) dated 02 Dec 2009.
2. That I have the following
dependents(s) whose photographs are affixed below on this affidavit:-
Name
Relationship Age Date of Birth Part II Order No
Divya Bhardwaj (Daughter) 14 Yrs 10.08.98 6 TTR/155/18/99
Rukmesh Bhardwaj (Son) 12 Yrs 12.06.00
3. (a) That the combined monthly income (from all sources including income accruing from house/other immovable property/fixed deposit etc) of my dependant father and/or dependent mother is less that Rs 3500/-
(b) That is hereby certified that my parents(father/mother or both) do not draw and pension from central Govt/State Govt/PSUs/any Private Organisation and are physically residing with me.
4. That my child/Children is/are dependent on me and is/are NOT earning more that Rs. 3500/-per month and that my daughter is NOT married.
5. I shall inform the ECHS immediately
of her employment of earning more that Rs 3500/- PM.
6. that in case of any change in the status of my dependants(due to death, marriage, employment)), I will inform Station Headquarters, ECHS Cell at the earliest and will stop use of ECHS facilities. I will refund in full, the cost of any treatment that my dependant may have received after he/she became ineligible. I shall be liable for civil/criminal action should I fail to do so.
7. (a) That
I am NOT a member of any other medical scheme funded by
(b) That my spouse is NOT a member of CGHS or any other Govt
Scheme.
8. I understand that in case I have submitted any incorrect information, or if any ECHS Membership Card is misused or used by any unauthorised person, my membership will be cancelled without any notice or further hearing. In addition, I will forfeit my contribution and I will pay the entire cost of expenditure incurred on such unauthorised person(s). I will forfeit my membership automatically.
9. That
in case of any misuses of Smart Card(s) or tampering with bill or attempt to
defraud, once I become a member, I will forfeit my membership automatically.
10. I
undertake that in case of any misbehaviour, on my part with Polyclinic Staff,
My membership may be suspended/cancelled/terminated.
11. I
understand that the contribution I am making is a onetime token amount and is
not refundable even if I do not make use of any ECHS facility or opt out of
ECHS scheme.
12. If
my membership documents are found false/incorrect /forged, the expenditure
incurred on my/my dependant’s treatment will be recovered from me.
VERIFICATION I the deponent above named do hereby solemnly declared and verify that the contents of the above affidavit are true to the best of my knowledge and belief and nothing material has been concealed or suppressed there from.
Verified at _______on this_____day of Feb Year
Signature of Deponent
ATTESTATION
Certified
that the above statement is declared before me at Palwal on this______day of
Feb 2012. by DEPONENT Smt Anju Bhardwaj w/o No 15375921M Late Havildar Mohinder
Singh who is identified by
Sh. Ram Bharose Sharma S/o Sh Munshi Ram and Witness by Smt. Usha Rani
W/O Sh. Ram Bharose Sharma.
WITNESS
Signature of Witness No 1 Signature of Witness No 2
ATTESTED BY
MAGISTRATE/NOTARY PUBLIC
CERIFICATE FOR DECEASED OR DISABLED OR DISCHARGED
MILITARY PERSONNEL ,
EX – SERVICEMEN OF
FORCES
“Certifieid
that Number: _______ Rank: Ex-Havildar(Clerk) Name: ________ S/O
Late Sh. ________father of Master _______ Resident of
House No: ______, Shyam Nagar Colony, _________ belonging to the state of Haryana has served in the Army of the Para
Military Force From 10 Mar 1984 to 31 December 2000 and subsequently discharged
from service as under:-
·
Medical
Category :
‘AYE’
·
Reason for Discharged/Retirement : At
his own request on
Compassionate grounds
·
Death : NA
·
Weather
killed in action : NA
Or any other reason : NA
·
If
killed in action : NA
Name of
War/Operation : NA
·
Disabled
Whether disabled
during the war/operation : NA
(Name)
·
Nature
of Disability : NA
Whether permanent
i.e. for life : NA
Whether temporary
up to what extent : NA
Next RSMB is due : NA
Name of Records : The GRENADIERS
Signature of the Issuing Authority With designation and official Seal and stamp
Case
No:_______________
Date :
______________
Note: Only the certificate issued by the officer
duly authorized by the Army/Navy/Air Force/Concerned
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