S/O………………………………………. Vill:………………………………..

P.O……………………………….P.S…………………… Dist:……………….

at present working as………………………………………(designation) in the Office of the……………………………………………………………………..

under…………………………………. Department, state that I will retire from service on.…………………..on attaining the age of superannuation as my date of birth is……………………. which has been recorded in my Service Book.

I do hereby undertake that if Sri…………………………….. for whom I stand as surety, fails to repay the loan stipend availed by him for his study, the entire loan amount alongwith interest thereon, if any, shall be recovered from my pay, pension and gratuity.

Full signature with date

The employee is serving under my control and the above declaration is countersigned.

Seal and Signature of the Employer/

Head of Office