OLD AGE / WIDOW PENSION AFFIDAVIT
Executed at __________ on __________.
I, __________, __________, aged about __________ years (date of birth __________), resident of __________, holding __________, ordinarily resident within __________ (the "Deponent" or "I"), do hereby solemnly affirm and declare as follows:
- SCHEME APPLIED FOR
1.1 I am applying for __________, and I make this affidavit in support of that application for filing before __________.
- RESIDENCE AND ELIGIBILITY
2.1 I have been ordinarily resident within __________ for __________ years, and I continue to be ordinarily resident there as on the date of this affidavit.
2.2 My total annual family income, from all sources, is __________.
2.3 __________
- BANK ACCOUNT FOR DIRECT BENEFIT TRANSFER
3.1 The pension, if sanctioned, may be credited to the following account, which stands in my own name: __________
- DECLARATION
4.1 Every statement made above is true to my own knowledge and belief, and I have concealed nothing material to my eligibility for __________.
4.2 I am aware that this is a means-tested welfare benefit, that its continuance depends on the facts stated above remaining true, that I must report in writing to __________ any change in my income, any remarriage where this is a widow's pension, any other pension I come to receive, or any change of residence, that a benefit drawn on a false statement is recoverable, and that making a false declaration in a sworn affidavit is an offence.
VERIFICATION
Verified at __________ on __________ that the contents of paragraphs 1 to 4 above are true and correct to my own knowledge, that no part of it is false, and that nothing material has been concealed.
DEPONENT
Signature: ______________________________
__________
Left thumb impression (if unable to sign): ____________
ATTESTATION
Solemnly affirmed and signed before me on __________ at __________, the Deponent having been identified to my satisfaction by __________.
Notary Public / Oath Commissioner
Registration No. and seal: ____________________