CPPC S L NO CATEGORY............................................................................................................../NO................................. CERTIFICATE TO BE SUBMITTED BY THE PENSIONER 1.

LIFE CERTIFICATE Certified that I have seen the Pensioner Shri ........................................................................................... holder of PPO No and that he is alive on this date. .. Signature of the Authorised Officer SIGNATURE OF THE PENSIONER Date: .. Designation with seal S B. A/C (PENSION) No. Address: - ... Name: .. S.S. No. (If State Bank Officer) 2. NON-EMPLOYMENT/RE-EMPLOYMENT CERTIFICATE I. I declare that I have not taken any employment in any capacity either in Government Department/Office/Company/Corporation/Autonomous Body or Society of Central or State Government or a Local Fund during the year ending 30th November 20. OR II I declare that I have not accepted any commercial appointment in or outside India. OR III. I declare that I have not accepted any employment under the Government outside India/an International Organisation of which the Government of India is not a member. AND I undertake to inform the Bank promptly on accepting any employment OR IV. I declare that I have accepted Commercial employment in India after obtaining provisional sanction of the concerned. Government and none of the conditions, if any, attached therein by the Government has been violated and I am drawing salary as mentioned in para-VI, OR V. I declare that I have taken employment in..........................................as...................................and I am drawing salary as mentioned in para - VI VI. Basic pay..............................................Special pay........................................DA..........................Other allowances.......................................................Total S & A..................................................................... OR Honorarium........................................................ I declare that I am not getting any increment or allowance on account of my previous employment in which I am drawing this pension. I further declare that the order of my employment or the pension rule governing the pension which I am drawing to, do not stipulate my pension in full or any part component being held in abeyance during the employment period. Place: .......................... .. Date: .. SIGNATURE OF THE PENSIONER 3. NON-MARRIAGE/REMARRIAGE CERTIFICATE I hereby declare that I am not married/I have not been married/re-married and I undertake so report such an event promptly to the Bank. Place: .. Date: .. SIGNATURE OF THE PENSIONER 4. UNDERTAKING I. I undertake to self-assess, pay income Tax and file the income Tax Return in respect of my pension, if required and inform the Bank. II. I hereby undertake to refund any excess payment credited to my account due to delay in receipt or any information or any bonafide error pertaining to payment of my monthly pension and authorise Bank to recover such excess payment from my account and/or the pension payable to me. III. I certify to the best of my knowledge and belief that the above declarations are correct. Place: ......................... .. Date: .. SIGNATURE OF THE PENSIONER Signature of the Authorised Officer verified Signature/L.T.I. of the pensioner verification. I certify to the best of knowledge and belief that the above declaration is correct. Forwarded FOR USE AT THE BRANCH to CPCC, Bhubaneswar for necessary action. NAME OF THE BRANCH ....................................................... ....................................., CODE SIGNATURE OF THE PENSION PAYING OFFICER/ ACCOUNTANT/BRANCH MANAGER (With Seal) NAME: .SS No..................