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Annexure : IV

FORM – C

(FOR PENSIONER/FAMILY PENSIONER ONLY)

 

(INCOME /SALARY CERTIFICATE FOR THOSE GUARDIANS WHO ARE IN PENSION (RETIRED FROM SERVICE OR THEIR WIVES ARE GETTING FAMILY PENSION

PART – I		:	Income from Pension /FamilyPension :
1.	Name and address of the Ex-Employer			:
	with P.P.O. No.

 

1. Certified that __________________________________________________ was employed in this Organisation/superannuated from in the capacity of

__________________________(post held by the retired employee) and that the

break-up of his/her Annual Income from Pension /Family Pension received in the financial year____________ is as follows :

 

	ITEM	TOTAL AMOUNT FOR 12 MONTHS
i)	Basic Pension/F. Pension	:
ii)	Dearness Relief	:
iii)	Other Allowances,
	Arrears,  if any	:
	_________________________________________
	Total	:

_________________________________________

Signature of Ex-Employer/Pension
Disbursing Authority : _______________________

Designation : ______________________________
Date :

                                                                    (Official Stamp)

 

 

Contd…2

: 2:

PART – II   :                       Income from Other Sources

DECLARATION BY THE PARENT/ GUARDIAN

I declare that my/my family’s Annual Income from other sources during the Financial Year

____________________ was as follows in addition to my pension income:

Income from:		Amount in Rs.
a)	Landed Properties (Certificate from Tahsildar/Gram Panchayat)
b)	Agriculture
c)	Investment in Bank/Post Office/Unit Trust etc.
d)	Share Certificates/Debentures
e)	Other Sources
f)	Total of Salary Income as stated in item No.2  of Part-I , ( Pl. see pre-page)
Gross Total Annual Income (add all of the above)		Rs.

 

Further, I declare that the information given above is true. I shall also be personally held responsible in the event of any information or documents provided by me are found to be incorrect/false.

 

Date :	Signature of the Father /Guardian	:
	Full Name	:
	Address with Pin Code	:
	Phone No. & e-mail ID

N.B. : Those

Pensioners who need not  to file  Income

Tax Return (ITR) due to Low Annual

Pension/Income, they must have to submit attested copies of Income & Non-Employment Certificate from local District Authorities like S.D.O. / B.D.O. /M.R.O./ TAHSILDAR, Anchal Officer, Local Municipal Corporation etc. as applicable along with Annual Pension Certificate duly filled in as per above stated format (Form-C, Annexure- IV)

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