FORMAT-C
RE-EMPLOYMENT /NON RE-EMPLOYMENT CERTIFICATE
I Smt/Shri _____________________________ widow/sondaughter/F/M of No
__________________ Rank __________ Name _____________________________, resident
of Village ____________________ PO ______________________ Teshil
_________________
Distt _______________________ State __________ do hereby solemnly declared
that :-
“the above named deceased soldier was not re-employed in civil
(Government or Private org) after retirement from the Army/DSC services. I
am also not in receipt of any kind of family pension from any sources”
OR
“the above deceased soldier was re-employed in civil (Government or
Private) org) ie _______________________________________________ after retirement
from the Army/DSC services. I am not in receipt of any kind of family pension
from any sources.”
I further solemnly affirm that the contents of above declaration are
correct and true to the best of my knowledge. If any statement is proved to be
incorrect or false in later stage, we the undersignee and witnesses shall be
liable penal refund of family pension drawn.
(Signature/Thumb impression of claimant)
Signature of two witness preferably the Indian Military Pensioners :-
1. Name _______________________ Army No ____________________Rank _________
RO/HO/ Village ________________________ PO ________________________________
Tehl ___________________________ District ____________________________________
PPO No _________________________________ Signature _________________________
2. Name _______________________ Army No ____________________Rank _________
RO/HO/ Village ________________________ PO ________________________________
Tehl ___________________________ District ____________________________________
PPO No _________________________________ Signature _________________________
ATTESTATION
(Signature and seal of Village/Municipal level)
Officer or any officer who able to do so with seal
COUNTERSIGNED BY RO
Station : ________________
Dated : ______________
Note : If the deceased soldier is re-employed is re-employed then must be
furnished part II-III & IV of this certificate.
PART - II
In case of deceased was re-employed after his retirement from military
service :-
(a) No ________________ Rank ________ Name _______________________
(b) Department in which the deceased soldier was re-employed ______
______________________
(c) Date of re-employment ______________________
(d) Date of retirement of retired __________________
(e) Date of death _______________________________
(f) Post in which employed _____________________________________
(g) Whether re-employed permanent/temporary ____________________
(h) Whether family pension is admissible/admitted to NOK - Yes/NO
(j) If family pension is not admissible give the reasons
_________________
___________________________________
(k) If family pension admissible/admitted give the following details :-
(i) Name of pension scheme ________________________________
(ii) Whether it is Government or bank or provident fund pension
scheme ___________________________________________
(iv) Pension payment order of pension granted ________________
(v) Rate of family pension admissible __________________________
Office Seal
(Signature of re-employing authority
Dated : With name and post seal
DETAILS OF SAVING BANK ACCOUNT
1. Beneficiary Details :-
(a) Name and Contact Person : Smt_________________________
(b) Home address : Village : ______________________
PO : ______________________
Teh : ______________________
Distt : Bilaspur (HP)
(c) Contact No : _____________________________
2. Particulars of Bank Account :-
(a) Account Title : ___________________________________
(b) Name of the Bank : ____________________________________
(c) Name of the Branch : ____________________________________
(d) IFSC Code No : ____________________________________
(d) Address :-
(i) Village : _______________________
Post Office : _______________________
Tehsil : _______________________
District : Bilaspur (HP)
(ii) Telephone No : _______________________
(e) 9 Digit MICR Code Number of : _______________________
the bank and branch appearing on the
MICR cheque issued by the bank.
(f) Type of account (Saving or Current) : _______________________
(g) Account number (as appearing : _______________________
on the cheque book)
(Please attached a blank cancelled cheque original and photocopy of a cheque)
I hereby declare that the particulars given above are correct and complete. If the transaction is
delayed or not effected at all for reasons of in complete or incorrect information. I would not hold the user
institution responsible. I have read the option invitation letter and agree to discharge the responsibility
expected of me as a participant under the scheme.
Dated : ____________________ (Signature of Account Holder)
Smt ____________________Wd/M/F of
No ____________________Rank ______
Name: Late ________________________
Certified that the particulars furnished above are correct as per our records.
Dated : _________________ (Signature of Authority / Bank Manager)
With rubber stamp
COUNTERSIGNED
Place : ZSW, Bilaspur (HP) (Signature of Zila Sainik Welfare)
Dated : _________________ With office seal
FORM OF WITNESSES
1. Signature of the FIRST Witness : ___________________________
Name of the Pensioner : ___________________________
Regimental No : ___________________________
Rank : ___________________________
Records Office : ___________________________
H.O Number : ___________________________
Bank Branch : ___________________________
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2. Signature of the Second Witness : ___________________________
Name of the Pensioner : ___________________________
Regimental No : ___________________________
Rank : ___________________________
Records Office : ___________________________
H.O Number : ___________________________
Bank Branch : ___________________________
COUNTERSIGNED
FAMILY DETAILS OF 1ST WEDLOOCK OF DECEASED SOLDIER
Name DOB Relation Marital Handicapped Present Remarks
Status or not employmen
(Married/ t
Unmarried
/
widow/
divorced)
NIL
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Place : ZSW, Bilaspur (HP)
Dated : Feb 2022
DETAILS OF HOME ADDRESS WITH PIN NO AND MOB NO IN R/O SMT
CHETNA KUMARI WIFE OF NO 3999210 LATE NK ROSHAN LAL
1. Smt Chetna Kumari widow of No 3999210 Late NK Roshan Lal.
2. Home address as under :-
Villiage - Karot
Post Office - Dobha
PS - Barmana
Tehsil - Sadar
Distt - Bilaspur
State - Himachal Pradesh
PIN - 174001
Mob No - 8580813428
e-mail - Nil
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Place : ZSW, Bilaspur (HP)
Dated : Feb 2022
