PROFORMA OF AFFIDAVIT FOR OBTAINING SURVIVING MEMBER CERTIFICATE I Smt. ____________________ w/o _______________ R/o ____________ do hereby solemnly affirm and declare as under: 1. That Sh. ____________________ S/o ___________________ expired at ______________ on _____________ and death was registered with MCD. Death Certificate No. _______________ dated ______________ is attached. 2. That after the death of my husband Sh. _______________________, the following are the survival members in the family. 3. That the none other than mentioned above is the survival member in the family. 4. That survival member certificate is required for submission in the Office of ___________________________. 5. That this is my true statement. Deponent Sl.No. Name Age Retation with deceased 1. 2. 3. 4. 5. Verification: Verified at Delhi, this _____________ day ___________ that the contents of the affidavit are true & correct to the best of my knowledge and belief and nothing has been concealed therein. Deponent
