ECHS : Self attested certificate form for dependent above 18 years – to be submitted every year for unblocking of Smart Cards

ECHS : Self attested certificate form for dependent above 18
years – to be submitted every year for unblocking of Smart Cards

Appendix ‘B’
(Refer to Para 5 of CO,

ECHS

letter No B/ 49711-NewSmart

Card/AG/ ECHS dt 29 Apr 2019
)


ECHS SELF ATTESTED CERTIFICATE FOR

DEPENDENT ABOVE 18 YEARS OF AGE

(TO BE SUBMITTED ONLINE EVERY YEAR FOR UNBLOCKING OF CARDS) 


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1. It is certified that Mr/ Mrs/ Ms _________‘A’_________

whose photograph is appended is a bonafied dependent

of No _________‘A’_________ Rank _________‘A’_________

Name _________‘A’_________

(Retired) with ECHS Card/ Registration No -_________‘A’_________

2. Particulars of Dependent Mr/ Mrs/ Ms _________‘A’_________

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(f) Date of Birth _________‘A’_________

(g) Aadhar No _________‘A’_________

(h) PAN Number _________‘A’_________

(i) Copy of 26AS for the following Assessment Year :-

(i) Last Assessment Year : ☺ (To be uploaded, if held)

(ii) Total Annual income as per Form 26AS: _____________

(e) Current Address of dependent. _______________________

3. It is also certified that Mr/ Mrs/ Ms _________‘A’_________ is not employed and is having no income.

4. It is also certified that Mr/ Ms _________‘A’_________ is not married (Not applicable for parents) .

Note:-

(a) This self declaration is valid for ONE Year from the
date of submission. 
(b) The cards of all dependents above 18 years of age will be blocked every
year and needs to be activated through online submission of this proforma . 
(c) In case of any change in dependency, the primary Card holder is
responsible to cancel the membership of dependent immediately on occurrence
by blocking the card on the online portal and intimation to his/ her
parent/ nearest polyclinic.

Any false declaration/ misuse of benefits will entail suspension/
cancellation of ECHS membership of all members. 

I, __Name of Ex-servicemen (Autopopulated)__, do hereby solemnly
declare and verify that the contents of the above declaration are true
to the best of my knowledge and belief, and nothing material has been
concealed or suppressed therefrom. This electronic self declaration has
been given with reference to IT Act 2000 and is admissible under The
Indian Evidence Act 1872. 





⃞ Agree

Date : ______‘A’_______
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echs-self-attested-certificate




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