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    Self Attested Proforma For Children

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    Barun Kumar Singh
    This document is a self-attested proforma for certifying a dependent son or daughter over 18 years of age for an ex-serviceman's ECHS (Ex-Servicemen Contributory Health Scheme) card. It includes the dependent's name and photo, date of birth, identification numbers, address, and certifications that they are not employed, married, or earning income. The proforma must be countersigned by an ECHS polyclinic officer and will be valid for one year, after which a new proforma must be completed. Any changes in dependency or false declarations could result in suspension or cancellation of ECHS membership.

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    © All Rights Reserved
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    Self Attested Proforma For Children

    Uploaded by

    Barun Kumar Singh
    2K views1 page
    This document is a self-attested proforma for certifying a dependent son or daughter over 18 years of age for an ex-serviceman's ECHS (Ex-Servicemen Contributory Health Scheme) card. It includes the dependent's name and photo, date of birth, identification numbers, address, and certifications that they are not employed, married, or earning income. The proforma must be countersigned by an ECHS polyclinic officer and will be valid for one year, after which a new proforma must be completed. Any changes in dependency or false declarations could result in suspension or cancellation of ECHS membership.

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    Self Attested Proforma for Children

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    This document is a self-attested proforma for certifying a dependent son or daughter over 18 years of age for an ex-serviceman's ECHS (Ex-Servicemen Contributory Health Scheme) card. It includes the dependent's name and photo, date of birth, identification numbers, address, and certifications that they are not employed, married, or earning income. The proforma must be countersigned by an ECHS polyclinic officer and will be valid for one year, after which a new proforma must be completed. Any changes in dependency or false declarations could result in suspension or cancellation of ECHS membership.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views1 page

    Self Attested Proforma For Children

    Uploaded by

    Barun Kumar Singh
    This document is a self-attested proforma for certifying a dependent son or daughter over 18 years of age for an ex-serviceman's ECHS (Ex-Servicemen Contributory Health Scheme) card. It includes the dependent's name and photo, date of birth, identification numbers, address, and certifications that they are not employed, married, or earning income. The proforma must be countersigned by an ECHS polyclinic officer and will be valid for one year, after which a new proforma must be completed. Any changes in dependency or false declarations could result in suspension or cancellation of ECHS membership.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    ECHS SELF ATTESTED PROFORMA FOR DEPENDENT SON/DAUGHTER

    ABOVE 18 YEARS OF AGE

    1. It is certified that Master / Miss ____________________________ LATEST


    whosePhotograph is appended is a bonafied dependent Son / Daughter of SELF
    ATTESTED
    No._________________ Rank _________ Name ____________________
    PHOTO
    (Retired) with ECHS Card / Receipt No._____________________________.
    PP SIZE

    2. Particulars of Dependent Master / Miss _______________________

    (a) Date of Birth ________________________

    (b) Aadhar No._________________________

    (c) PAN No.___________________________

    (d) Address____________________________

    3. It is also certified that Master / Miss ______________________is not employed and is having no
    income.

    4. It is also certified that Master / Miss ______________________ is not married.

    Note: The self attested proforma alongwith countersignature of OIC parent ECHS Polyclinic, 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, after which dependents need to prepare a fresh proforma. In case
    of any change in dependency, the primary card holder is responsible to cancel the membership of dependent
    immediately on occurrence. Any false declaration / misuse of benefits will entail suspension /
    cancellation of ECHS membership.

    ___________________________ __________________________
    (Signature of Dependent) (Signature of Ex-serviceman /
    Primary Member)

    Date: ______________________ Place:_____________________

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