AFFIDAVIT

AFFIDAVIT ON RS. 50/- NON JUDICAL STAMP PAPER AND TO BE ATTESTED BY

MAGISTRATE/ NOTARY PUBLIC DELCARATION

I, Service No 28325 Rank EX- NK Subedar Name Smt. Vidya Devi W/o
Late Tej Singh of (Unit) 6, Mahar Reg. Solemnly Affirm and Declare as follows
1.
That I am / Will be drawing pension vide PCDA Pension Payment Order No.
S/011040/1966 Dated 24 Dec 2013 or ( In the case of widow/ Family
Pensioner)
In the Following legal depndant (s) Whose Photograph (s) is/ Are affixed below on this
affiedavit
S.No
Name
Relationshi
Age/ Date
Parti Order
Remarks
.
p
of Birth
No.
1
Smt. Vidya Devi
Self
10/05/1938

Indeficiation Marks.....................................................................
S.No
.

Name

Relationshi
p

Age/ Date
of Birth

Parti Order
No.

Indeficiation Marks.....................................................................

Remarks

S.No
.

Name

Relationshi
p

Age/ Date
of Birth

Parti Order
No.

Remarks

Indeficiation Marks.....................................................................
Signed photo of dependant giving name, Relationship and indetification marks photograph (s)
posted and signed across by each dependant, in case of challenged child/ minor to be signed
by applicant.
3 (a) That the combined monthly income ( form all sources including income accuring from
house other immovable property/ fixed deposits etc.) of my dependant father / or dependent
mother is less than Rs. 3500/(b) That is hereby certified that my parents (father/ mother or both) do not drawn pension
from central (govt./ State Govt/ PSUs/ Any proviate origanisation and residing with me.
4.
That my child/ children is/ are dependant on me and is/ are not earning more than
Rs. ............./ per month and that my daughter (s) is/ are not NOT married. it Shall inform the
ECHS immediately of his/ her their employment (earning more than Rs. 3500 PM)
5.
The is case of Amy change in the status of my dependants ( due to death, marriage
employment) i will inform my station headquarter ECHS cell at the will shop use of HCHS
facilities. I refund in full the cost of any at my dependent my have received after he/ he
become indelible I shall will criminal action should i fail to do so.
6 (a) That i am not a member of any other medical scheme funded by Central Govt. PSU or
any other Govt. Undertaking i will immediately inform STn HQ if I am reemployed in the
Army and I am aware that my membership will remain suspended during reemployment.

(b)

That my spouse is not employed in Govt./ Public sector and is not a mention CGHS ro

any other Govt. Scheme.

7.

Understand that in case i have submitted any incorrect infomation or if my ECHS

membership card is misued or used by unathorised person, my membership wil be cancelled

with any notice or further hearing, in addition, I will forfeit my contribution and I will pay the

entire cost of expenditure incurred on wuch unauthrixed person (s) I wll also e liable for legal
action by the ECHS organisation i will slso immediately report loss my ECHS membership
card to station Headquarters and lodge an FIR with the local civil police.
8.

I am not in possession of my serice. / Discharge book ( if applicable)

9.

That is case of army misuse of smart and (s) or tempering will bills or attempt to
defraud once i become a member, will forfeit my membership automatically.

10.

I undertake that in Case of any misbehaviors, on amy part polyclinic staff my

membership my suspended/ Cancelled by the MD ECHS.

11.

I understand that the Contribution i am making is a one time token amount and in
nonrefundable even if i do not make use of any ECHS facilities.

12.

I No 28325 Rank Ex NK Subedar Name Smt. Vidya Devi W/o Late Tej Singh Do
hereby affirm that i on verification of the document the particulars of my depends
mentioned for dependency on each are found to be false/ incorrect/ forged then
undertake to refund / make good the money spend on teh treatment of such non
entitled persons.

SIGNATURE OF DEPONENT.

VERIFICATION
I the deponent above named do here by solemnly declare verify that the contents of the
above affidavit are ture to the best of my knowledge and belief. and nothing material had
been concealed or supersed therefrom
Verfied at Place Sagar on the (Date) 30 Day of Month Sep (Year) 2015

SIGNATURE OF DEPONENT

ATTESTATION
Certified that the above statement is declared before me at (place) Sagar on this 30
Day of Month Sep. 2015 (Year) by Dependent Service No. 28325 Rank Ex NK Subedar Name
Vidya Devi W/o Late Tej Singh Who is identified by name Smt. Neela Khatri W/o Anil Khatri
(First Indemnified) and witness name by Darshana Rajput W/o Shri Brajesh Rajput (Second
Identified)
SIGNATURE OF THE INDENTIFIED. ........................................................

SIGNATURE OF WINTNESS NO. 1

Smt. Neela Khatri W/o Anil Khatri
ADD :- Guru Govind Singh Ward Sagar
(M.P.)

SIGNATURE OF WINTNESS NO. 1

Darshana Rajput W/o Shri Brajesh Rajput
Add Rajakhedi Makroniya Sagar (M.P.)