I, _________ Son of _________ resident of _________ a _________ of _________ do hereby solemnly affirm and declare as under:
1. That my Child/Children Namely (I) _________ Son/Daughter was born on _________
(II) _________Son/daughter was born on _________
2. That above named son & Daughter is/are unemployed and is/are fully dependent on me.
3. That above named son& daughter is/are unmarried as on date.
4. That in case he/she starts earning or gets married, whichever takes place earlier, I will inform the _________ for discontinuance of the medical facility provided to him.
Verified at _________ on this _________, _________ that the contents of above affidavit are true and correct to the best of my knowledge and belief and nothing has been concealed there from.