Life Certificate for Pensioners – Application format with Non-Employment Certificate

STATE BANK OF INDIA
CERTIFICATE TO BE SUBMITTED BY PENSIONER
A) LIFE CERTIFICATE

Certified that I have seen the pensioner_________________________________ (Name of pensioner),

holder of Pension Payment Order No._______________________ and he / she is alive on this date.

Savings Bank A/c No.

Name & Designation of Authorised Officer_____________________

Specimen Signature of pensioner_____________________

Seal

Place:

Date

B) NON-EMPLOYMENT CERTIFICATE

# I declare that I have not received any remuneration for serving in any capacity in an establishment of Central Government or a State Government or a Government Undertaking or from a Local Fund during the period November_______________ to October_____.

# I declare that I have been employed / re-employed in the office of_________________ and

was in receipt of the following emoluments during the period____________

# I declare that I have not accepted any employment under any Government outside India, after obtaining / without obtaining sanction of the EPF organization (to be furnished by Class I officer only)

# Delete whichever is not applicable.

Signature_____________________

Name of Pensioner______________

PPO No. ___________

Place:

C) CERTIFICATE OF RE-MARRIAGE / NON-MARRIAGE

I hereby declare that I am not married / have not married during the past twelve months. Signature

Name of Pensioner_______________

PPO No.____________

Place:

________________________________________________

I certify to the best of my knowledge and belief that the above declaration is correct. Signature of a responsible officer/well known person

Name:

Designation:

Place:

Date:

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