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

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

 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)
 

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’_________

(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’_______