Affidavit

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.

DEPONENT

VERIFICATION: –

Verified at ________ on ________ that the contents of the above affidavit are true and correct to best of my knowledge and belief.

Witness:

1. ________
2. ________