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Self Attested Proforma For Children

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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Barun Kumar Singh
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2K views

Self Attested Proforma For Children

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.

Uploaded by

Barun Kumar Singh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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