Application format of Life Certificate for Pensioners.

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: