Declaration of Family Members for Medical Purpose

DECLARATION OF FAMILY MEMBERS FOR MEDICAL PURPOSE

Name of Employee: ......

Designation : ......

Department: ......

NAME DATE OF BIRTH RELATIONSHIP EMPLOYMENT STATUS

1.1 Certified that my spouse is not employed/is employed but does not avail medical facility from his/her employer (to be supported by a declaration from the employer of the spouse).

1.2Certified that my parents as declared above are wholly dependent on me and the total income of any of my dependents from all sources* is not more than Rs. 6,000/- per month (to be supported by an undertaking that medical facility is not being availed from any other source and that they are residing with the employee – format enclosed***).

1.3 Certified that other dependents (Other than parents) as declared above are wholly dependent on me and the individual monthly income from all sources* does not exceed Rs. 3,000/- per month.

*(Income from land and property, rent from house/building, interest from Bank and other deposits, dividend from investments commuted pension as also pensionary equivalent arising out of CPF and like)

NOTE :The amount of scholarship/stipend received by the dependent children of the employee will not be treated as income for deciding the dependency of the employee.

1.4.Certified that my dependent widowed sister and/or dependent parents/parents-in-law** are permanently residing with me.

2.0. I further note that furnishing of wrong information in the above declaration would make me liable to disciplinary action which may even amount to dismissal. I also undertake to inform the Company of any change in the above list of dependents immediately when it occurs.

NOTE : DEFINITION OF "FAMILY"

i. The employee's wife or husband as the case may be;

ii. Legitimate children and step-children wholly dependent on the employee;

iii. Minor brothers and minor un-married sisters or widowed sisters wholly dependent and residing with employee if the father is not alive or wholly dependent on, and is residing with the employee;

iv. Parents if they are wholly dependent on and residing with the employee.

**v.Parents-in-law (Only at the option of female spouse of the deceased employee appointed on compassionate ground in place of parents).

…………………………………………………….

Full Signature of the Employee

Residential address:

Date: Permanent Address:

UNDERTAKING FOR THE PURPOSE OF

MEDICAL REIMBURSEMENT

I, hereby, undertake that my dependent parents (mother/father) is/are not availing medical facility from Central/State Govt./PSU or any other source and is/are residing with the undersigned.

Signature :

Name :

Designation:

Department: