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ANNUAL VERIFICATION CERTIFICATE

(GOVT.MEMO NO.28407-A/239/PSC/07,DT:4/1/2008)
1 Type of Pension Service Pension / Family
Pension
2 Name of Individua Smt.KARRI AMARAVATHI
S/o.D/o.W/o.H/o W/o KARRI VEERACHARYULU
3 Date of Birth / Age 15-01-1963 47 years Photo attested by Bank Manager/
4 P.P.O. No 22- FG -003840 Gazetted Officer

5 Name of Bank and Branch SBI, Dondaparthy, Visakhapatnam


6 Bank Account No Old New

10667624121
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7 Employment Particulars
(Applicable if Re-Employed after retirement /
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Appointed on Compassionate Grounds)

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a) Name of Office

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b) Date of Employment/
Re-Employment
c) What is the D.A being drawn on lic
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employment
d) Date from which D.A is Drawn
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8 Re-marriage Particulars if any
a) Date of Re-marriage
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b) Name of the spouse

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9 Present Residential address with
Phone No.
10 Pan No. if any __
DECLARATION OF THE PENSIONER
I hereby declare that:
i. I am not drawing any other pension
ii. I am drawing other pension through PPO No
iii. I am not drawing any D.R on that pension
iv. The particulars mentioned above are true to the best of my knowledge and belief.
v. If the above particulars proved wrong at any time, I am liable for disciplinary / criminal action as per rules

Left hand Thumb


Impression of the Pensioner
(Signature of the Pensioner)
Date:
Place:
CERTIFICATE-1
(To be issued by the Drawing & Disbursing Officer)

Certified That Smt./Sri.___________. W/o._________ was appointed as ___________ on Compassionate Grounds on this office
with effect from_____ She/He is being paid the Dearness Allowance eligible to her at the rates sanctioned by the government from time
to time.

As per the declaration filed by the individual, she / he is not drwaing any D.R on the family pension being drawn vide PPO
No._________ from the Sub-Treasury / Pension pPayment Office.

Station:
Date: Signature & Office Seal

CERTIFICATE-II
Certified That I have seen the pensioner as on November 2010 and he/she is alive

Signature of the Treasury Officer Signature of the Gazetted Officer/


i.e. STO/ATO/APPO (With name and seal)
Bank Manager / Notary
(With name & Seal)
NOTE:
i The Pension Disbursing Officer can sign the Certificate if the pensioner appears personally before the Pension Disbursing Officer.

ii. If pensioner does not appear personally before the Pension Disbursing Officer, the Certificate shall be signed by any Gazetted
Officer / Bank Manager.
iii. The Annual Verification Certificate are obtained from 1st November on wards.
iv. The Non-receipt of the Annual Verification Certificate the pension shall be stopped from 1st April on wards (i.e) March payable on
1st April.
ACKNOWLEDGEMENT
Received the annual Verification Certificate date: Nov.2010 of Sri./ Smt. Karri Amaravathi Holder of PPO No 22-FG-003840

Receiver Signature , Date & Stamp.


CATION CERTIFICATE
07-A/239/PSC/07,DT:4/1/2008)

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