To

The Treasury Officer,

North Tripura District,

Kilashahar.

Sir,

I do hereby undertakes/identify to refund the amount of arrear payment of pension/relief etc paid to me at any time.

Signature of pensioner

P.P.O. No.____________________

Certified that I have not been any service/occupation since my retirement from service.

Signature of pensioner

I do hereby declare that I am not re-married/employed after the death of my husband/wife.

Signature of pensioner

I certify that to the best of my knowledge and belief that the above declaration is correct.

Signature of responsible

Officer/ a well known person

Name & address:-

Designation:-