ECHS Smart Card: Self Attested Certificate From for Dependents – Submission at the time of collection of Card

Appendix ‘A’
(Refer to Para 3 of CO, ECHS
letter No 8/49711-NewSmart Card/
AG/ ECHS dt 29 Apr 2019)

2. Particulars of Dependent Mr/ Mrs/ Ms ___ ___ ___ ___ ___ ___

(a) Date of Birth ___ ___ ___ ___ ___
(b) Aadhar No ___ ___ ___ ___ ___
(c) PAN Number ___ ___ ___ ___ ___ (if held)
(d) Copy of 26AS for the following Assessment Year :- (if held)
(i) Last Assessment Years : ___ ___ ___ ___ ___

(e) Current Address of dependant ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___

3. It is also certified that Mr/ Mrs/ Ms ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
is not employed and is having no income/ income is less than Rs 9000 PM
plus DA.

4. It is also certified that Mr/ Ms ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ is
not married (Not applicable for parents).

Note:-

(a) The self attested proforma will be produced whenever required in ECHS
polyclinic/ empanelled hospital by the beneficiary. The validity of the same
will be ONE Year from the date of signature.

(b) 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.