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

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

“Revised Application Format of Life Certificate for Pensioners”

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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