I Smt. ____________________ w/o _______________ and M/o______________________R/o ____________ do hereby
solemnly affirm and declare as under:-
1. That Sh. ____________________ S/o ___________________ expired at ______________ on _____________ and death was registered with MCD. Death Certificate No. _______________ dated ______________ is attached.
2. That after the death of my son Sh. _______________________, the following are the survival members in the family.
Sr. No. Name Age Relation with deceased
That the none other than mentioned above is the survival member in the family.
4. That Full and Final Settlement is required to be paid to the nominee who is the mother of the deceased and a survival member, including PF, ESI and other claim be processed to the survival member of the family.
5. That this is my true statement.
Verification: Verified at Delhi, this _____________ day ___________ that the contents of the affidavit are true & correct to the best of my knowledge and belief and nothing has been concealed therein.
Seniors or other members are welcomed to modify/change the formats if required
1st February 2017 From India, Ahmadabad