Annexure to SB Order No 36/2021

Self Declaration

(To be submitted by the MPKBY Agents for non –mentioning of ASLAAS-5 Card numbers in
the RD Schedule (Bulk List)

I, Y. RAJESWARI (Name of the MPKBY Agent) W/o/D/o Y. MALLESWARA RAO

Certificate of Authority No MIG0032893 valid up to 03-02-2027 (date) residing at Nalla Veedhi,
Vizianagaram. Declare that the following accounts have been canvassed by me and I could not
provide ASLAAS-5 cards to the Depositors as the ASLAAS-5 cards were not supplied to me by
the Appointing Authority of MPKBY Agent.

S No Account No Name of the Depositor Date of opening Monthly Deposit

of Account amount in Rs
2. I declare that I am fully responsible for the money of the Deposits of the RDAccounts to
whom I am serving as agent.

3. I declare that the commission payable to me may be adjusted/recovered by Department of

Posts, in case of any objection raised by the Competent Authorities in respect of RD deposits
collected and credited by me. I shall also abide by the rules of Department of Posts time to time
and I am liable for taking any action as per extant rules in case of deviation of anything which
cause inconvenience to the Depositors and as well to the Department of Posts.

Signature of the MPKBY Agent

Certificate of Authority No………………
Date :