~~~m~,1995

EMPLOYEES' PENSION SCHEME,

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1995

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~rH~cIl!5Of

LIFE CERTIFICATE AND NON-REMARRIAGE

~/lnstructions

1.

~
1l

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\Jl11Tfcnm \ifAT ~

liThe

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1N?r 1l

the Pension beneficiaries

2,

X1lfr

m 11T<fT, ~

Life Certificate
including

should

children

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<r6

WfTUTq?f \Nf

Certificate

4.

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m~ m et> ~
5.

\Jffii

may be given by the Manager

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widower

-mm et> ~,

\Jl11T<PXrrr

pensioner

pension

only ..

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Gl

only

m 11T<fT qJf 'lrfl Name

ofthe

qrf ~

should

\JffiTI

is to furnish

of November;

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is to be furnished

should

be furnished

tr.f~

have seen the pensioner

qfUfcr

whose

details

uficA'

<m-

every year by

of commencement

of

in duplicate.

-q.'lj.~

'fi./P.P.O.No.

mml

~/Bank

ffl'dT

t 1/

\JfT ~

is disbursed;

<PT <r6

it at the time

by all

be given for each

N, ~

Pensioner

I.

x=ffim/S.B. A/c No.

Branch

WfTUTq?f/L1FE CERTIFICATE

11T<fT <PT ~

t 3tR cm

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et> ~aN/~

~ I I Certifi

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are given above and that he/she

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~I

fcn<n

\JfRT t I ~

I/This certificate

______________

~ I

tifCldRd

Certificate

111"5

qrf ~

given below

every year in the month

of Non-remarriage

Pensioner

_________________

wrrfUm fcom \JffiTI t fcp

in the format

of the Bank by which the pension

ma- 1l \JflIT fcn<n \JfRT ~

t~ ~

'4T wrfi'R;r

be furnished

I/Separate

xf

t I/Certificate

Widow

Gl ~

pensioner

pensioner;
3.

CERTIFICATE

ed th at I

is alive on this date.

et> f.1m;:r/Signature/Thumb
et> ~/Guardian

impression
of Minor

of pensioner

Children

Pensioner

Place

Date

et> ~

3tR ~

~/Signature

ofthe

Manager

with Bank Seal

11.~;:fRl(m; rr
(Cf

(~~

cf; ~

qJf

"fl'./PPO NO.

wnur LT?[/CERTIFICATEOF NON RE-MARRIAGE

cr.m ffrrt ~

0fR WIT

m ~/(Applicable

to widow family pensioner

and to be furnished only once.)

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m tiRh1,<01

I~

t ~~;:fRl(m; m ~ ~

~;:fRlcM rr5f fcpm ~. cr.m <l5 zyrr ~

if ~

II I hereby declare that I have not re-married and I

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undertake to report such an event promptly to the Pension Disbursing Agency/EPFO

(~sr) (~~

if <'fTlJ.- ~

cf; ~

qtf ~

l1ffi

if WIT

m ~/(Applicable

to widower family

pensioner to be submitted in the month of November every year)

~

&m ~ ~

t ~tf;f

CfiTI

3ll\Jf

(j'Cf)

~;:fRlcm5rr5f fcpm ~ I1I hereby declare that I have not got

re-married till date.

I Place

~I

Date

~ ~

CImlT

t ~~

cf; f.imrr/Signature/Thumb

cf; 6WaR/~

~ ~ \J11'1Cf>I~ ~

if ~

impression of pensioner

~ 1/1 certify to the best of my knowledge

and belief that the above declaration is correct

ftldlC:I'<

3f~

cf; 6WaR

\J1loil"iloi ~

Signature of responsible officer or a well-known

~ I Place
~I
bate

f.1Rl" ~

tiRld,<01 ~
CfiT ~

~I

~/For

cf; ~
cf; lfJtZIl1 ~

person

~/Name

3BH'lIRd

Designation

the use of Disbursing Branch

I wnur LT?[~ ~

m=fr mT ~ I/Forwarded

to

Regional P.F. Commissioner through Link Branch. One copy of the above certificate is retained.

I Place

~I

Date

~tTCP cf; 6WaR/Signature

Cf>ltlfliltl ~/Office

(~

f.1Rl" ~

Cf>Aj~C:,< if

Cf)'{ ~

cf; Cf>ltlflilll ~

fcpm

'Tml (~~

~/(For
~

of Manager

Seal

the use of Regional P.F. Commissioner's Office)

~ ~

if ~

~/Entered

in the

Computer (Bank Reconciliation statement) for updation. (To be preserved in the PPO file)

~.Xj.~

(~

mm) I S.S.A., Pension

-Rm ~

(m ~)/A.O.,

Pension