Transcription of DECLARATION & CERTIFICATE FOR …
1 (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.
2 (to be given by a legiti-mate/adopted infirm son or by a legitimate/adopted infirm daughter. CERTIFICATE as specified, tobe attached, if required)Present Address : _____Signature or Thumb-impressionDate _____of the dependantor_____Name in Block LettersSignature or Thumb-impression of theof signing claimantGuardian in case of a minor of the minor_____Through_____ (name of the Guardian)his/her _____(relationship with the Minor) CERTIFICATE ** Certified that _____ w/s/d of_____ is alive this day, the _____ day of _____of 20_____and that the declarations made above are true to the best of my knowledge and *Please strike out whichever is not applicable.
3 **This CERTIFICATE is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department : or (ii) aMunicipal Commissioner : or (iii) a Workmen s Compensation Commissioner: or (iv) the Head of gram Panchayatunder the official seal of the Panchayat; or (v) an ; or (vi) A Gazetted Officer of the Central/StateGovt. or (vii) a member of the Regional Board/Local Committee of the ESIC : or (viii) any other authorityconsidered appropriate by the Branch Manager :Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit,whether for himself or for some other person, commits an offence punishable with imprisonment fora term which may extend up to six months or with a fine up to Rs.
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