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(As per para 8.3 of G.O.Ms.No 213, Finance Department, dt. 19-12-1997)

I hereby declare that I am not married/ I have not been married during the past six months.
* I hereby declare that I have not been re-married and I undertake to report such an event promptly
to the Treasury/Bank.
* Applicable only for widow receipient of family pension to be furnished.

Signature : ____________________________________
Name of the Pensioner :
P.P.O. No. ______________________________________
Place :

Date :
I certify to the best of my knowledge and belief that the above declaration is correct.

Signature of a responsible
Officer or a well known
Person : __________________________________
Name : ___________________________________
Designation : ______________________________

Place :
Date :