ACKNOWLEDGEMENT FORM

1. Present Address
2. I certify that I am not remarried as on date of above mentioned cheques
Date of remarriage(in case of widow only)
3. Details of children :
S.No

Name

Date of Birth

Class

Married(Y/N)

Employed(Y/N)

1
2

Date _________________

Signature & Name of Beneficiary

Certified that the above details as furnished by the individual are correct
Date & Office Seal
Verified by Gazetted Officer/Village Sarpanch
or
in case of employed, employer's authorisation