I hereby declare that I have not been re-married and I undertake to report such an event promptly to the Pension Disbursing Authority / Bank.
Place: _________ Signature: _________
Date: _________ Name of the Pensioner: _________
I certify to the best of my knowledge and belief that the above declaration is correct.
Place: _________ Signature of a responsible
Date: _________ Officer or a well – known Person
Name: _________
Designation: _______