UNDERTAKING

I, Mustafizur Rahman, working as a 'Graduate Teacher (Science)' at Shawrachara M.K.

Higher Secondary School, Barpeta, do hereby undertake that I want to opt-out from 'Mukhya
Mantri Lok Sevak Arogya Yojana (MMLSAY)' scheme of the State Government of Assam. I don't
want to avail any benefits under this scheme.

REASON : Spouse has already availed MMLSAY Scheme and covered me as a dependent
along with nominee and have some financial problem.

Signature of Employee

Signature of DDO. Name : Mustafizur Rahman

Date : Desig.: Graduate Teacher (Science)

Office: Shawrachara M.K. H.S. School

Date : 05/02/2024