AFFIDAVIT

AFFIDAVIT ON RS. 10/- NON JUDICAL STAMP PAPER AND TO BE

ATTESTED BY MAGISTRATE/ NOTARY PUBLIC DELCARATION

I, Service No 5699143N Rank SEP Name RAM SWARUP AWASTHI of (Unit) D.S.C.
Solemnly affirm and declare as follows :1.

That I am / will be drawing pension vide PCDA Pension payment order No

SC/001851/1993 Dated 11/01/2016 or (in the case of window/ family pensioner )

I have the following legal dependant 9s) whose photograph (s) is / are affixed below on this
affideavit.
Sr. No.
1

Name
RAM SWARUP
AWASTHI

Relationship
SELF

Age/ Date of
Birth
12/05/1941

Party Order
No.

Remarks

Party Order
No.

Remarks

Party Order
No.

Remarks

Indenfication Marks .....................................................................

Sr. No.
2

Name
SMT. CHAMPA
BAI

Relationship
WIFE

Age/ Date of
Birth
01/01/1949

Indenfication Marks .....................................................................

Sr. No.

Name

Relationship

Age/ Date of
Birth

Indenfication Marks .....................................................................

Indentification Marks

..........................................................................................
..........................................................................................

Signed photo of dependant Giving name. Relationship and indetification mark photograph
(s) posted and signed accross by each dependant, in case of challenged chaild/ minor, to be
signed by Applicant.

(a)

That the combined monthly income (from all sources including income

accruing from house/ other immovalble property/ fixed deposites etc./ of my

dependant father and/ or dependent mother is less than Rs. 3500/(b)

That is here by certified that my parents (father/ mother or borth) do not draw

any pension from central govt/ state Govt/ PSUs) any private organisation ad are
physially resident with me
4.

That my child/ children is/ are dependent on me and is/ are not earning more than Rs.
3500/- per monthand that my daughter (s) is /are not NOT married. I shall infrom the
ECHs Immediately of his/ her their employment (earning more than Rs. 3500 PM)

5.

Thia is case of any change in the status of my dependents (due to death marriage
employment) i will informs my station headquarter ECHS cell at the earlist and will
stop use of ECHS facilities. I will refund. in full the cost of any treatment that my
dependency have received after he/ he become ineligible. I shall be liable for civil/
criminal action should if 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
recmployed 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 section and not a member of
CGHS or any other Govt. Scheme.

7.

I understand that in case i have submitted any incorrect information or if my ECHS

membership card is missed or used by unauthorized person. my membership will be
cancelled without any notice or further hearing. In addition. I will forfeit my
contribution and i will pay the entire cost of expenditure incurred on such
unauthorized person (s). I will also be liable for legal action by the ECHS
organisation I Will aso immediately report loss fo my ECHS membership card to
station Headquarters and lodge on FIR with local civil police.

8.

I am not in possession of my serivce. Discharge book ( if appliable)

9.

That in case of any misuse of sarmt and (s) or tempering will bills or attempt to
defraud once I became a member, will forfeit my membership sutomatically.

10.

I undertake that in case of any misbehavious, on my part polyclinic staff my

membership may be suspended/ cancelled by The MD ECHS.

11.

I Understand that the contribution I am making is a one tome token amount and in
nonefundable evern if do not make use of any ECHS facilities.

12.

I no 6599143 N Rank SEP Name RAM SWARUP AWASTHI do here by affirm

that. if on verfification of the document the particiulars of my dependents mentioned
for dependecy on each are found to be false/ incorrect/ forged then undertake to
refund/ make good the money spend on the 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 and ture to the best of my knowledge and belief and nothing
material has been concealed or supersedes there from.
Verified at (place) SAGAR on the (date) 17 day of (month) FEB- 2016

SIGNATURE OF DEPONENT

ATTESTATION
Certified that the above statment is delcared before me at (place) SAGAR is this 17
day to (month) FEBUARY (year) 2016 by DEPNENT service No6599143 N Rank SEP
Name RAM SWARUP AWASTHI Who is Identified by name RAM SWARUP AWASTHI
S/o (fathers Name of Indetified) LATE LAXMAN PRASAD and witnessed by name
AJAY KUMAR S/o fathers Name of First Witness RAM SWARUP AWASTHI and name
CHAIN SINGH (fathers name of second wintess) JWALA SINGH
SIGNATURE OF THE IDENTIFIED........................................

SIGNATURE OF WITNESS NO.

NAME OF BLOCK CAPITALS
JAY KUMAR S/O RAM SWARUP
AWASTHI
FULL POSTAL ADDRESS
VILLAGE KANKAR KUIA DISTT.
SAGAR

SIGNATURE OF WITNESS NO. 2

NAME OF BOCK CAPITLS
CHAIN SINGH S/O JWALA SINGH
FULL PASTAL ADDRESS
VILLAGE KANKAR KUIA DISTT.
SAGAR

ATTESTED BY MAGISTERE/ NOTARY PUBLIC