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ANNEXURE
To, Date:
The Assistant General Manager
Union Bank of India, HR Suvidha
Sub: Declaration of Dependent(s) for LFt
| have applied for LFC on declaration/LFC Advance/LFC Final Claim as on for my
travel. from to under LFC Block from, to
& LFC Term from to ***. In this regard, | would like to
declare the following: (Tick the relevant/ applicable boxes)
[J 1. Idectare that none of the Family members (other than spouse) shown as dependents have
income exceeding Rs.10000/-p.m. from any source and are covered under the definition of
Family as per X" Bi-partite Settlement/Joint Note dated 25.05.2015 (Staff Circular No.
6211 and 6212 dated 30.06.2015)
C1 2. | dectare that child/children for whom the LFC is being claimed as dependent (s) is/are
unmarried (including step children and legally adopted children).
(1 3. | declare that my Parents or Parents-in-law for whom LFC is claimed as dependent (s) do
not have individual or aggregate income exceeding Rs.10000/-p.m. from any source and
they are wholly dependent on me. | further declare that no other member of my Parent's
family or Parents-in-law family or my spouse will be claiming this facility for them.
1 4. I dectare that my Spouse (if working in Union Bank of India) has not availed LFC in my
above 4 year block or will not avail LFC until my above 4 year Block expires.
5. | declare that my daughter/s for whom LFC is being claimed is/are widowed/divorced/
separated and is/are wholly dependent on me.
6. | declare that my sister/s for whom LFC is being claimed is/are
unmarried/divorced/abandoned/widowed/separated from husband and is/are wholly
dependent on me.
O 7. | dectare that my brother / sister for whom LFC is claimed is/are physically/mentally
challenged with 40% or more disability and is/are wholly dependent on me.
Details of dependents for whom | want to claim LFC (All fields are mandatory)
Name] Relationship | Occupation Warried? Please mention | Basis of | Physically”
(student housewife, | Unmarried Monthly income | arriving at | mentally
employed/unemployed, | Widowed/divorced | in Rs. monthly challenged
ensioner/family Separated. (Refer (Refer point No 1 | income (Refer point
pensioner etc) point no 2,5 &6) &3) No7)
(Yes/No)
Thereby confirm that the aforesaid information given by me is correct and as per the
definition of family described in Bi-partite Settlement/Joint Note dated 25.05.2015. If any
statement is found to be incorrect/false later on, the Bank has right to recover the LFC amount
sanctioned to me and initiate disciplinary action as per the provisions of disciplinary
rules/regulations applicable to me.
Yours faithfully
** Note:
Officers: 4 years LFC block/2 years LFC term Signature of the employee
‘Award Staff: 2 years LFC block/2years LFC term Name:
4 years LFC Block/4 years LFC term Emp. No:
Phone No:
