I ________ aged ________ years Son/daughter/widow of Late ________ Resident of ________ hereby solemnly affirm and declare as under: –
1. That I am ________ of Late ________ Son of ________ who was working as a ________ expired on ________.
2. That Late ________ had left the following member behind him.
|Sl. No.||Name||Age||Relationship with deceased|
3. That I am the legal heir of Late ________ and natural guardian of my ________ children mentioned at ________ above.
4. That I am the only ________ of Late ________.
5. That I am entitled for payment of ________ /- (________ Only) out of the fund.
6. That apart of the family members indicated in para no. – ________ above, there is no ________ family member heir of Late ________.
7. That it is established that I have concealed/suppressed any facts that I will be squarely responsible for the including the refund/recovery of Benevolent fund recovered by me.
Verified at ________ on ________ that the contents of the above affidavit are true and correct to best of my knowledge and belief.