Draft of affidavit for Military Deceased Pension | Affidavit for getting pension of deceased army man

Draft of affidavit for Military Deceased Pension | Affidavit for getting pension of deceased army man


I, Smt. __________wife of _____________ Late Sh. _________, R/o ________________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

3. 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/-       

4. That is hereby certified that my parents(father/mother or both) do not draw and pension from central Govt/State Govt/PSUs/any Private Organization and are physically residing with me.

5. 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.

6.  I shall inform the ECHS immediately of her employment of earning more that Rs 3500/- PM

7. 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.

8-       (a)    That I am NOT a member of any other medical scheme funded by Central Govt, PSU or any  other  Govt Undertaking.

  (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 unauthorized 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 misbehavior, 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- Thar 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 ________ 

                                                                                             Signature of Deponent


Certified that the above statement is declared before me at _______ on this______day of Feb ______. by DEPONENT Smt.  ______________ who is identified by  Sh. _____________________




            ATTESTED BY


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