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    GRT LC

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    fcipensiondoknl
    This document contains an annual life certificate form to be submitted by an ex-employee or member beneficiary at the beginning of each financial year. It includes fields for the employee number, name of the ex-employee or deceased member's beneficiary, and a certification section to be signed by the ex-employee/beneficiary and attested by an authorized certifying authority such as a bank manager, medical practitioner, or government officer. The certifying authority confirms the identity of the ex-employee/beneficiary and that they appeared before them on the specified date. Contact information for the ex-employee/beneficiary such as email, phone numbers are also collected.

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    © All Rights Reserved
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    GRT LC

    Uploaded by

    fcipensiondoknl
    12 views1 page
    This document contains an annual life certificate form to be submitted by an ex-employee or member beneficiary at the beginning of each financial year. It includes fields for the employee number, name of the ex-employee or deceased member's beneficiary, and a certification section to be signed by the ex-employee/beneficiary and attested by an authorized certifying authority such as a bank manager, medical practitioner, or government officer. The certifying authority confirms the identity of the ex-employee/beneficiary and that they appeared before them on the specified date. Contact information for the ex-employee/beneficiary such as email, phone numbers are also collected.

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    This document contains an annual life certificate form to be submitted by an ex-employee or member beneficiary at the beginning of each financial year. It includes fields for the employee number, name of the ex-employee or deceased member's beneficiary, and a certification section to be signed by the ex-employee/beneficiary and attested by an authorized certifying authority such as a bank manager, medical practitioner, or government officer. The certifying authority confirms the identity of the ex-employee/beneficiary and that they appeared before them on the specified date. Contact information for the ex-employee/beneficiary such as email, phone numbers are also collected.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    12 views1 page

    GRT LC

    Uploaded by

    fcipensiondoknl
    This document contains an annual life certificate form to be submitted by an ex-employee or member beneficiary at the beginning of each financial year. It includes fields for the employee number, name of the ex-employee or deceased member's beneficiary, and a certification section to be signed by the ex-employee/beneficiary and attested by an authorized certifying authority such as a bank manager, medical practitioner, or government officer. The certifying authority confirms the identity of the ex-employee/beneficiary and that they appeared before them on the specified date. Contact information for the ex-employee/beneficiary such as email, phone numbers are also collected.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Anne xure- IV

    ANNUAL LIFE CERTIFICATE . .


    {To be subm itted by ex-employee/member bene f the
    ficiary at the begin nmg 0
    financial year)
    1. Employee No. :

    2. Name of the Ex-employee/ member beneficiary


    (in case of deceased employee): G,,, R, "\ • ESW M~ ~<E- DD'!
    [The below mentioned Fonn should be signed on
    or after 1st of April of every
    finan dal year by the Ex-employee/ Member benef
    iciary (in case of deceased
    employee} 'and A I IESTEll_ by 111,y of the following offici
    al(s}:
    Bank Branch Mana ger/ ctaletted Officer / Registered
    Medical Practitioner I Post
    Master I School or College Principal / Class-I Office
    r of any Government or Semi
    Government or Quasi Government or Government
    Undertaking or Public Sector
    . Undertaking/GAIL Executive]

    "I, ?. \M ,M_ )d/AS k+IA hereby certify that Shr i/~


    G, · A. 'I I"" Sw,MU R(D,:Juse/Son/Dau!;jbter/
    appeared before me on o Ii 2-D 2..'1
    of @,~WI \ bl 1\-N DI ll@ D'./--
    personally
    and has signed in my presence and his/her
    signature is attested below~ I am fully satisfied about
    his/her identity".
    Dated at ~ ~ ~ l - - = = - - this o9, day of l"anucbj 20"1

    ~NKL]'-
    Counte § ~of

    *
    '
    u d

    Mem ber ---- ---" '-- Certifying Authori


    {Stamped)
    06
    01
    .;,
    0
    °' ,o,)
    ")J)~'-'
    ~~= -== ==~ ·---- -
    0 Y- Le,~
    Name: f c- ~,w AA '" SHA
    Designation: _l) ~ \ . l ~ 1S"C \~ rro":)e__g
    • Add
    Offiace ress: U_c,c.., ~Qtl ~\
    ':J

    R5)iu'l-,
    Set~ c2.wo. . No__f!t __rte..
    ~\GY\ a~cD, s: , :51) , • ..A.- "
    Contact Number: i2-t tq.4 09o 3,
    ID No.: l..\""- ~ \:,

    Ex-employee's / Member beneficiary's email ID:


    Cs? 1~1f RED 'D'j (i \'
    Residential Telephone Number:

    4
    Mobil e Numb er: _ _ _ _ _9_4-..._9 Oh 3 3 9'6
    ************

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