(echs) application form - Bureau of Naviks

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SAMPLE FOR AFFIDAVIT
AFFIDAVIT ON RS. 10/- NON JUDICIAL STAMP PAPER AND TO BE ATTESTED BY MAGISTRATE/NOTARY
PUBLIC DECLARATION
DECLARATION
I, Service No. ………………….. Rank …………… Name …………………………..
of unit Indian Coast Guard solemnly affirm and declare as follows :-
or
I, ……………………………………. Wife/father/mother/daughter/son of Service No………………..
Rank……………………………. Name………………………………..of (Unit) …………………………………. Solemnly affirm
and declare as follows
1. Than I am/will be drawing pension vide PCDA Pension Payment Order No.
…………………………………………………………….. dated ………………..

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2. That I have the following legal dependent(s) whose photographs(s) is/are affixed below on this
Affidavit :-
Name :
Photo
Date of Birth :
Relationship :
Identification Mark :
Name :
Photo
Date of Birth :
Relationship :
Identification Mark: .
Name :
Photo
Date of Birth :
Relationship :
Identification Mark :
Name :
Photo
Date of Birth :
Relationship :
Identification Mark :
(Photograph(s) to be pasted and signed by the applicant)

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3. (a) That the combined monthly income (from all sources including income accruing from
house/other immovable property /fixed deposit etc) of my dependent father and /or
dependent mother is less than Rs. 3500/-.
(b) That it is hereby certified that my parents (father/mother or both) do not draw any pension
from Central Govt/State Govt/PSUs/ any Private Organisation and are physically residing with me.
4. That my child/children is/are dependent on me and is /are NOT earning more than Rs. 3500/-
per month & that my daughter(s) is /are NOT married.
5. I shall inform the ECHS immediately of his /her/their employment of earning more than Rs.
3500/- P.M.
6. That in case of any change in the status of my dependents (due to death, marriage,
employment), I will inform Station Headquarters, ECHS Cell at the earliest and will stop use of ECHS
facilities. I will refund, in full, the cost of any treatment that my dependent may have received after
he/she become ineligible. I shall be liable for civil/criminal action should I fail to do so.
7. (a) That I am NOT a member of any other medical scheme funded by Central Govt, PSU or any
other Govt undertaking. I will immediately inform Stn HQ if I am re-employed in the Army/Coast
Guard and I am aware that my membership will remain suspended during reemployment.
(b)
That my spouse is NOT a member of CGHS or any other Govt Scheme.
8. I understand that in case I have submitted any incorrect information, or if any
ECHS Membership Card is misused or used by any unauthorized person, my membership will be cancelled
without any notice or further hearing. In addition, I will forfeit my contribution and I will pay the entire cost
of expenditure incurred on such unauthorized person(s). I will forfeit my contribution and I will pay the entire
cost of expenditure incurred on such unauthorized person(s) I will also be liable for legal action by the ECHS
Organisation. I will also immediately report the loss of my ECHS membership card to the nearest Station
Headquarters.
9. That in case of any misuse of Smart Card(s) or tampering with bills or attempt to defraud, once I
became a member, I will forfeit my membership automatically.
10. I undertake that in case of any misbehavior, on my part with Polyclinic staff, my membership may be
suspended/cancelled/terminated.
11. I understand that the contribution I am making is a onetime token amount and is not refundable even
if I do not make use of any ECHS facility or opt out of ECHS Scheme.
Signature of Deponent

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VERIFICATION
I, the deponent above named, do hereby solemnly declare and verify that contents of the
above affidavit are true to the best of my knowledge and belief, and nothing material has been
concealed or suppressed there from. Verified at(place) ……………………….. On this (date) …….………
Day of month) ……………Year…………………….
Signature of deponent
ATTESTATION
Certified that the above statement is declared before me at (Place) …………….……….on this …………day
of (Month) ……………. Year ……….. by Deponent Name………………………..…………………… Service No.………….
Rank………………… Who is identified by Name ………………………………… S/o ………………………….. and witnessed
by Name…………………………… S/o……………………………….. And Name…………………………………….. S/o
…………………………………..
WITNESS
Signature of Witness No. 1
Signature of Witness No.2
(Name in Block Capitals)
(Full postal address)
(Name in Block Capitals)
(Full postal address)
ATTESTED BY MAGISTRATE/NOTARY PUBLIC

MILITARY RECEIVABLE ORDER
Bank's Counterfoil(To be forwarded to the CDA)
(To be filled by MRO issuing authority)
Received a sum of Rs.
Total(Rs in words)
___Crores _____Lakhs ____ Thousands ____Hundred _____Tens ___ units
From ………………………………………………………………………………………………. (Name/Rank/P.No. of the individual)
By Cash/Cheque No. ………….Date…………….. Bank …………… for credit to PCDA(WC) CHANDIGARH (Code No: 4013000004) on
account of "EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)”
MAJOR HEAD : 0076, MINOR HEAD: 107, COMPLIABLE TO CODE HEAD: 0/405/01
BSR Code DD MM YY Serial No.
Bank Seal
Signature of Pensioner/Issuing Authority
Depositor's Counterfoil-1 (To be retained by the Depositor)
(To be filled up by Treasury/RBI/SBI Bank)
Treasury/RBI/Bank …………………………….. Dated :‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Received a sum of Rs…………………(Rupees …………………………………………………….. only) from ……………………………………………………………………..
………..(Individual/Unit/Officer) on account of "EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)” for credit to
PCDA(WC) CHANDIGARH as Defence Receipts
MAJOR HEAD : 0076, MINOR HEAD: 107, COMPLIABLE TO CODE HEAD: 0/405/01
o
BSR Code DD MM Serial No.
YY
Bank Seal
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Depositor's Counterfoil-2 (To be forwarded to PCDA/CDA)
(To be filled up by Treasury/RBI/SBI Bank)
Treasury/RBI/Bank …………………………….. Dated :‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Received a sum of Rs………………… (Rupees …………………………………………………….. only) from ________________________________________
………………….. (Individual/Unit/Officer) on account of "EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)” for credit to
PCDA(WC) CHANDIGARH as Defence Receipts
MAJOR HEAD : 0076, MINOR HEAD: 107, COMPLIABLE TO CODE HEAD: 0/405/01
BSR Code DD MM YY Serial No.
Bank Seal
………………………………………………………………………………………………………………………….…………………………………………………………
Depositor's Counterfoil-3 (To be retained by Stn. HQ/Regional Centre)
(To be filled up by Treasury/RBI/SBI Bank)
Treasury/RBI/Bank …………………………….. Dated :‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Received a sum of Rs…………………(Rupees ………………………………………..………………………… only) from …………………………………………………
…………………………… (Individual/Unit/Officer) on account of "EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)” for credit
to PCDA(WC) CHANDIGARH as Defence Receipts
MAJOR HEAD : 0076, MINOR HEAD: 107, COMPLIABLE TO CODE HEAD: 0/405/01
BSR Code DD MM YY Serial No.
Bank Seal

14
BANKER’S CERTIFICATE
Certified that following :
Name ………………………………………………………… Service No. ………………. Rank ………………
Pension Account No ……………………………. of this bank is drawing pension as follow :
(a) Uncommuted Basic Pension Rs. ……………….
Including 50% Dearness Pension
(b) DA Rs. ……………….
(c) Fixed Medical Allowance Rs. .……………
------------------
Total :
Rs
His Pension Payment Order No. is ………………………………………………….
Fixed Medical Allowance has been stopped w.e.f. (date)………………………
------------------
(Authority for discontinuation of FMA, CGDA New Delhi Circular No. 5601/AT – P/Paytt dated 17 Jun 05
and GOI, MOD letter No. 2(a)/01/US(WE)/D (Res) dated 30 Dec 2002)
Date :
PDA/Bank Manager/I/C DPDO
(With Official Stamp)

BUREAU OF NAVIKS
GENERAL INSTRUCTIONS FOR FILLING-UP THE ECHS APPLICATION FORM
1. Application to be filled up in capital letter with ball point pen, ink pen not to be used. No overwriting is
allowed.
2. While filling up the form, leave one box blank after each completed word.
3. Applicant must sign/thumb impression should be clear without any overwriting with black ink within
the boxes proved on the pages 1 & 4 (part-IV).
4. The boxes provided at the end of pages 1, 3 and 4 (part V) in the form are to be left blank for Record
Officer’s signature and stamp.
5. Abbreviations such as Mr.Mrs.& Shri..etc NOT to be written before the name in the boxes.
6. Copy of Pension Payment Order (PPO), duly attested by Bank from where pension is being
drawn to be enclosed.
7. Bankers Certificate to be made as per page no.14. Stoppage date of Fixed Medical Allowance to be
mentioned (if mentioned in PPO).
8.. UID Number of Aadhar Card to be mentioned in application and duly attested photo copy
of the same must be enclosed.
9. Recent colour(CLEAR AND SHARP) passport size photographs (Red Background) of self and the
dependants are to be pasted in the appropriate boxes provided in the Application form without signing on
them. Scanned/ computerized/small and poor image quality photos are not permitted.
10. A single demand draft of the total amount @ Rs. 135/- per member ‘x’ number of smart cards,
required to be made in favour of REGIONAL CENTRE, ECHS, DELHI CANTT” payable at DELHI, (The
individual’s Name, Rank & No. to be written on the reverse side of the DD) having validity of 2-3 months at
the time of reaching ECHS Cell, Bureau of Naviks.
11. ECHS Contribution be made through MRO at RBI/SBI in favour of PCDA (WC) Chandigarh, on
account of “Ex-servicemen Contributory Health Scheme (ECHS)”. Two copies (in original) of the
same to be enclosed with application.
12. Affidavit to be filled up on Rs.10/- NON JUDICIAL STAMP PAPER as per the sample and duly
attested by the Magistrate/Notary with the round stamp and signature having the following: -
(i) Para 1 to 11
(ii) Photographs signed across by the Applicant
(iii) Date of Birth, Relation and Identification mark of all the members to be written (as per the
service document) below the photograph, DOB should strictly match with the Application from.
(iv) Attestation to be filled correctly. i.e. particulars of Identifier and 02 witnesses.
(v) Signature and full postal address of two witnesses.
13. Lab report of Blood Group for self and dependent must be enclosed.
14. Parent polyclinic to be filled in application must be nearest to the residential address of each member.
List of polyclinics is at page no.13.
15. Additional photo copy of fully filled and updated application to be enclosed.