Transcription of DECLARATION & CERTIFICATE FOR …
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DECLARATION & CERTIFICATE FOR …
(To be submitted along with claim of June & December)REG. FORM 24 DECLARATION & CERTIFICATE FOR DEPENDANTS BENEFITEMPLOYEES STATE INSURANCE CORPORATION.(Regulation 107-A)Name of the deceased Insured Person _____ Ins. _____ being the _____ of the above-nameddeceased Insured Person and also being his dependant, do hereby solemnly declare :-* (i)that I have not married*/remarried so far. (to be given only by a female dependant).*(ii)that I have not yet attained the age of 18 years. (to be given only in respect of a minor male orfemale dependant)*(iii)that I have attained the age of eighteen years but continue to be infirm.
(To be submitted along with claim of June & December) REG. FORM 24 DECLARATION & CERTIFICATE FOR DEPENDANTS™ BENEFIT …
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DECLARATION CERTIFICATE FOR LOCAL, DECLARATION CERTIFICATE FOR LOCAL PRODUCTION, PENNSYLVANIA EXEMPTION CERTIFICATE This, Declaration, Certificate, LOCAL, Hill Commission Local Government Conference, Hill Commission Local Government Conference ENFORCEMENT, Application for Certificate of Title With/Without