AFVOA Newletters of Year 2003

Page 26 of 170 221 West Bengal Kolkata 222 West Bengal Bengdubi(Jalpalguri) 223 West Bengal Barasat 224 West Bengal Krishnanagar 225 West Bengal Bardwan 226 West Bengal Hawrah 227 West Bengal Midnapur AFFIDAVIT on Rs 10 Non Judicial Stamp Paper and attested by a Magistrate I DEPONENTS NAME, RELATION WITH PENSIONER<illegible> <illegible> 1. That I am drawing pension <illegible> Pension Payment Order________<illegible>_________ 2. That I have <illegible>: (a) NAME, RELATIONSHIP, AGE, DATE OF BIRTH <illegible> Order No & date for all dependents other than father and mother). Signed photo of Dependant giving name, relationship Identification mark Signed photo of Dependant giving name, relationship Identification mark 3. That the income of my father & mother from all sources is less than Rs 1500/- per month. 4. That my sons are not employed and that my daughters are not employed or married. 5. That I am aware of the fact that my sons are not eligible for the Ex-servicemen Contributory Health Scheme after they attain 25 years of age or get employed before that age. 6. That I am aware of the fact that my daughters are not eligible for the Ex-servicemen Contributory Health Scheme after they marry or get employed. 7. That in case of any change in the status of my dependents(due to death, marriage, employment), I will inform my regional headquarters ECHS at the earliest and will stop use of this facility. I will refund in full the cost of any treatment that a dependent may have received after he/she became ineligible for the same. 8. That I am not a member of any medical scheme funded by the Central Government, State Government, Public Sector Undertaking or any Government Undertaking. Signature of Deponent I, the deponent above named do hereby verify that the contents of the above affidavit are true to the best of my knowledge and belief and nothing material has been concealed or supressed therefrom. Verified at (PLACE) on this (DATE) day of (MONTH) (YEAR) Signature of Deponent