I. ANNEXURE - III(To be submitted in the month of January, each year)

[ See para 50, Pension Manual]

ToThe Chief Manager (Pension)&Pension Sanctioning AuthorityThe Kolkata Municipal Corporation5, S. N. Banerjee Road. Kol-13

I hereby certify that the following Pensioner/Family Pensioner of KMC appeared beforeme this day and is alive :-Name: p.p.a. No. :Bank's Name:Bank A/ c No. :Dated:

Signature of Authorised Signatoryalong with Seal & Date

II. EMPLOYMENTjNON-EMPLOYMENT CERTIFICATE(To be signed by the Pensioner/Family Pensioner of KMC)

r:jf' I declare that I have not received any remuneration for serving in any capacity inan establishment of the Central/State Government or a Government undertakingor from local fund during the period from 1st January to 31st December last year.

r:jf' I declare that I have been employed/re-employed, in the office of the............................... and was/is receipt of the following remuneration duringthe period from to .Basic Pay Rs D. A. Rs Other allowances Rs .

r:jf' I DECLARE THAT I HAVE ACCEPTED/NOT ACCEPTED COMMERCIALEMPLOYMENT OR EMPLOYMENT UNDER ANY ORGANISATION OUTSIDEIndia after obtaining/without obtaining prior sanction of the authority competentto sanction pension/ family pension to me.

r:jf' The above statement is true.

Dated:

Note: Copies of this form should be availableat paying bank supplied by KMC throughlink bank.

SignaturejLTI of the PensionerName in Full .Address: .

HALF-YEARLY DECLA.RATION OF FAMILY PENSIONERSWHOSE FA.MILY PENSIONS ARE TERMINABLE ON THEIRMj\RRIAGE OR RE-l\tIARRIAGE

(To be submitted. in January and July each year)

1) Family Pension Payment Order No .

I de hereby declare that I am not married and tha: 1 have not been married in the pastduring last six months.

I hereby declare that I have not b=en re-married. I undertake to report such an eventpromptly to the bank/ pension disbursement authority.

Signature or LII of Family Pensioner

vVidow /Widower / Daughter of

La te .

Address .

N. B. Sh'ike out which is not applicable.

TO BE SIGNED BY THE RESPONSIBLE OFFICERS OR WELL-KNOWNAND TRUSTIVORTHY PERSONS OF THE LOCALITY

We certify that to the best of our knowledge and belief the above statement given by thefamily pensioner is correct.

2) (i) Signature : .

(ii) Name infull ./''') A 'd~111,' Gress " .

(ii) Name in full .

(iii) Add ress : : .

Note .: Copies of this form should be available nlpayillg banksupplied by KMe through link bank.