Affidavit of dependency
For a family pension, CGHS/medical claim or an employer's records.
Opens Dastavo with this paper ready to fill, on this computer or in the app. No account needed.
iPhone and iPad: coming to the App Store · Android: coming to Google Play
Not yet reviewed by a lawyer. Check every line before it is signed.
How the paper begins
With Dastavo's sample details; the people and places are fictional. The words in blue are the ones you fill in.
AFFIDAVIT
(Dependency)
I, Balwant Kaur widow of late Shri Jagir Singh, aged about 67 years, resident of Village Kalyanpur, Tehsil and District Amarnagar, Punjab, do hereby solemnly affirm and declare as under:
1.That I am the mother of Gurdev Singh and live with him or her.
2.That I am wholly dependent on Gurdev Singh, and my own income is nil.
3.That I am making this affidavit for his medical reimbursement claim.
DEPONENT
VERIFICATION: Verified at Amarnagar on this 12th day of October 2026 that the contents of paragraphs 1 to 3 of the above affidavit are true and correct to the best of my knowledge and belief, and nothing material has been concealed therein.
DEPONENT
What to bring
Papers to bring
- Aadhaar card or another photo identity proof (photocopy; the original to show)
- Proof of your relationship with the employee or pensioner
- Proof of your own income, if you have any, such as a pension slip, an income-tax return or an income certificate
- The office's form for dependants, with the employee's or pensioner's ID card, CGHS card or PPO, as the case may be
- Two recent passport-size photographs
Where to go
Sworn before an Oath Commissioner or Notary, then given through the employee or pensioner to the employer's office, the CGHS wellness centre or the pension office.
Fee
The e-Stamp paper and the Oath Commissioner's or Notary's fee are paid at the counter; ask there for today's amounts.
Good to know
- Whether a parent or other relative counts as a dependant depends on an income limit in the rules; the office checks your income.
- The affidavit says you live with the employee: some offices check that the addresses match.
- Tell the office when your income changes; benefits paid after that may be recovered.
Papers and fees can change. Check with the office before you go. Guidance only, not yet reviewed by a lawyer.
Stamp paper
Punjab: affidavits are usually typed on e-stamp paper (buy it at an authorised e-stamp centre; check the current duty there) and sworn before an Oath Commissioner or Notary. Many state services now accept a self-declaration instead.
Haryana: use e-stamp paper (egrashry / authorised vendors; check the current duty) and swear before an Oath Commissioner or Notary.
Chandigarh: e-stamp paper from an authorised centre (check the current duty); sworn before an Oath Commissioner or Notary.