Life Certificate to be Submitted by Pensioner Once a Year in November

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ANNEXURE-XVII
(See para 15.1 page 11 of
CPAO's Scheme Booklet) 
Part-A (Every year)
(To be submitted by Pensioner once a year in November)

Certified that I have seen the pensioner Shri/Smt./Ms._______________________________________ (Name of Pensioner) holder of Pension Payment Order No. _____________ and that he/she is alive on this date. 

1. Present address of the pensioner/family pensioner.
2. Telephone/Mobile number (if any).
3. E-mail Address (if any).

Name
Place:
Designation of Authorised Officer
Date:
Seal 

ACKNOWLEDGEMENT 

Life Certificate of Pensioner/Family Pensioner of Shri/Smt/Ms._________________________________ (Name of Pensioner) holder of Pension Payment Order No. ______________ has been received. 

Date:-
Signature ...................... 
Name ………………………….
Stamp of the receiving Bank branch

Source:- http://cpao.nic.in/pdf/life_certificate.pdf

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