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 Authorized 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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