Declaration As on 1st:

January July Year: 2025202620272028202920302031

I am:(Select Marital Status)	SELECT Unmarried Married and Spouse is an Employee Married but spouse is not an employee
Name of the office/School:
Name of the Employee:
Designation of the Employee:
Gender:	SELECT Male Female
Employees' Present Pay (Band Pay+Grade Pay):
HRA:
Opted for Swasthyasathi?	SELECT Yes No
Whether you get Swasthyasathi card?	SELECT Yes No
If Yes, then write the no. of card:

Name of the Spouse:
Name of the office (Spouse):
Address of the Office (Spouse):
Spouse's Present Pay (Band Pay+Grade Pay):
Spouse's HRA:
Whether spouse is opted for Govt. Housing:	SELECT Yes No
Whether spouse is opted for W.B. Health Scheme:	SELECT Yes No
Whether spouse is opted for under Swasthyasathi Scheme:	SELECT Yes No

Date: