Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015) (Page 13 of 17) in pdf

SAMPLE OF AFFIDAVIT

(For initial application)

AFFIDAVIT ON Rs. 10/- NON JUDICIAL STAMP PAPER and TO BE ATTESTED BY MAGISTRATE/NOTARY

PUBLIC DECLARATION

I Service No ________________ Rank ________ Name _____________________ (Unit) ______________,

solemnly affirm and declare as follows:-

I, ________________ wife/Father/Mother/Daughter/Son Service No_______________Rank____________

Name__________________________ of (unit) _________________________________ solemnly affirm and

declare as follows:-

That I am/will be drawing pension vide PCDA Pension Payment Order

No______________________________dated___________________

That I have the following legal dependent(s) whose photograph(s) is/are affixed below on this Affidavit :-

Name

Relationship

Age

Date of Birth

Part II Order No/CRD/SD/POR No

Signed Photo of Dependent giving name,

Relationship and Identification mark

(Photographs(s) to be pasted and signed across by the Applicant)

(a)

That the combined monthly income (from all sources including income accruing from house/other

immovable property/fixed deposit etc) of my dependant father and /or dependent mother is less than Rs

3500/- plus DA.

(b)

That is hereby certified that my parents (father/mother or both) do not draw any pension from

Central Govt/State Govt/PSUs/any Private Organisation and are physically residing with me.

That my child/ children is/are dependant on me and is/are NOT earning more than Rs. 3500/- plus DA per

month, & that my daughter(s) is/are NOT married.

I shall inform the ECHS immediately of his/her/their employment of earning more than Rs 3500/- plus DA.

That in case of any change in the status of my dependants (due to death, marriage, employment), I will

inform Station Headquarters, ECHS Cell at the earliest and will stop use of ECHS facilities. I will refund in full, the

cost of any treatment that my dependent may have received after he/she became ineligible. I shall be liable for

civil/criminal action should I fail to do so.

(a)

That I am NOT a member of any other medical scheme funded by Central Govt, PSU or any

other Govt undertaking.

(b)

That my spouse is NOT a member CGHS or any other Govt Scheme.

I understand that in case I have submitted any incorrect information, or if any ECHS Membership Card is

misused or used by any unauthorised person, my membership will be cancelled without any notice or further

hearing. In addition, I will forfeit my contribution and I will pay the entire cost of expenditure incurred on such

unauthorised person(s). I will also be liable for legal action by the ECHS Organisation. I will also immediately

report the loss of my ECHS membership card to the nearest Station Headquarters.

That in case of any misuse of Smart Cards(s) or tampering with bills or attempt to defraud, once I become

a member, I will forfeit my membership automatically.

10.

I undertake that in case of any misbehavior, on my part with Polyclinic Staff, my membership may be

suspended/cancelled/ terminated.

11.

I understand that the contribution I am making is a one time token amount and is not refundable even if I

do not make use of any ECHS facility or opt out of ECHS Scheme.

VERIFICATION

I, the deponent above named, do hereby solemnly declare and verify that the contents of the above affidavit are

true to the best of my knowledge and belief, and nothing material has been concealed or suppressed therefrom.

Verified at (place)-----------------------on this (date)-----------------day of (Month)---------------------------Year-----------

Signature of Deponent

ATTESTATION

Certified that the above statement is declared before me at (Place)---------on this ------------day of (Month)----------

Year--------by DEPONENT Service No ----------------Rank-----------Name----------------------------Who is identified by

Name---------------------------------------S/O (Father’s name of Identifier)---------------------------------- and witnessed by

Name---------------------------------------S/O (Father’s name of first witness)& Name------------------------------------- S/O

(Father’s name of second witness).

WITNESS

Signature of Witness No.1

Signature of Witness No.2

(Name in Block Capitals)

(Full Postal Address)

(Full Postal Address

ATTESTED BY

MAGISTRATE/NOTARY PUBLIC

Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015) Page 13

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