Wednesday, 8 May 2019

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

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 )

ECHS SELF ATTESTED CERTIFICATE FOR
DEPENDANT ABOVE 18 YEARS OF AGE
(AT THE TIME OF COLLECTION OF CARD)



Latest Self Attested Photo PP Size



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1. It is certified that Mr/ Mrs/ Ms__ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

whose photograph is appended is a bonafied dependant
of No ___ ___ ___ ___ ___ ___ Rank ___ ___ ___ ___ ___ ___
Name ___ ___ ___ ___ ___ ______ ___ ___ ___ ___ ___ (Retired)

with ECHS Card/ Registration No ___ ___ ___ ___ ___ ___ 

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.

___________________
(Signature of Dependant)

Place : ______________

Dated : _____________
______________________
(Signature of Ex-Servicemen /
Primary Member)

Place : ______________

Dated : _____________

echs-smart-card-self-attested-certificate-for-dependents-at-the-time-of-collection-of-card




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