ANNEXURE V FORM III DECLARATION (To be furnished with the pension bills every month) 1. I declare that: (i) I am not holding the elected office of the President/Vice President of India or appointed to the office of the Governor of any State or the Administrator of any State or the Administrator of any Union territory. (ii) I am not a member of the Council of States of the House of the People or any Legislative Assembly of a State or Union Territory pr Legislative Council of a State or the Metropolitan Council of Delhi. 1 Nor, am I employed 9n a salary under the Central Government or any State Government or any Corporation owned or controlled by the Central Government or any State Government or any local authority or become otherwise entitled to any remuneration from Government, Corporation or local authority. OR (iii) (a) lama member of........................... or Iam employed as ...: ...............................in ................................... and the total remuneration received by me, as being such member or being in such employment is Rs........................ (b) I am in receipt of pension of Rs. ........from...................... (iv) I am not in receipt of any pension from the Central Government or State Government or any Corporation owned or controlled by the Central Government or any State Government or any State Government or any local Authority. (v) In case of any overpayment resulting from clerical errors or due to lack of information regarding recovery of Government dues, such overpayment may be recovered from the amount of pension due to me in such manner as the Government may deem fit and proper. Dated:...................................... Pensioner's signature ............. .......... Place:.................... ................. Pensioner's name:...................... * Here mention the name ofthe office of the Central Government/State Government/ Corporation/Local Authority.
