Declaration format for Dependent Parents & Family Member

An employer may ask its employee to produce a dependency declaration certificate in case that employee is claiming any benefits for its dependents.

Dependent family members generally include in its purview an employee's wife or husband, unmarried children or step-children, divorced or widowed daughters, parents or step-mother. A female employee may include her parents-in-laws as her dependents.

Hereunder there are some examples of such dependency declaration certificates. You can modify them appropriately.

TEMPLATE #1

I hereby declare true to the best of my knowledge and belief that Smt./Sri./Kum. ________________ aged ____ years is solely dependent on me. He/She is not having any source of income either from land property or by way of any pension.

I hereby further declare true to the best of my knowledge and belief that Smt./Sri. _______________ aged ______ years is solely dependent on me. He/She is my Father/Mother and that he/she was not an employee and not having any source of income either from landed property or by way of any pension.

I affirm that if  any information is found false or contrary to my declaration, I shall be liable for any disciplinary or legal proceedings.

Signature

Name of the Employee/Pensioner

(Designation)

Dated ____________

TEMPLATE #2

I hereby declare that my father and mother are/ are not dependent on me. They are/ are not residing with me. Their monthly income from all reliable sources is/ is not more than Rs. ______/-.

2. My wife/ husband is working as a (Designation) in (Name of the Organization) at (Address). Or My wife/ husband is not working at present.

3. It is certified that at present my residential address is as given below:

_________________________________________________________.

4. The details of my family members is as given below:-

Sl. No.    Name            Date of Birth        Relationship

    1.

    2.

    3.

    4.

I solemnly affirm that the above declaration is true and I understand that in the event the above declaration is found incorrect then I shall be liable to be dismissed from my service.

    (Signature)

Name: _____________

Designation: ___________

Employee Code: ________

Dated ___________

Place: ___________

TEMPLATE #3

I, (Name of the Person), son/daughter of (Name of the Father) hereby declare that the following are members of my family who are wholly dependent on me.

I confirm that my father/mother is not a retired pensioner. Or the amount of pension drawn by my father/mother is Rs. ________/- PM as shown in the attached income certificate.

I further confirm that my husband/wife is not in service.(If in service — a certificate from the employer to the effect that he/she shall not avail the facility of LTC/ HTC/ Medical reimbursement from here.)

I further confirm that my children/step children claimed to be dependent do not have income exceeding Rs. ________/- per person per month from all sources including stipend and scholarship.

I undertake to inform (Name of the Organization) promptly in the event of any change in the status of any of the above mentioned persons and particulars.

I hereby affirm that the particulars of dependent members of my family as given hereinabove are correct. If any statement is found to be untrue, then I shall be liable for disciplinary and/or legal action.

Signature: __________

Name in block letters: _____________

Designation: ___________

Dated ___________

Place: ___________