PROFORMA
To
The (Designation of the Drawing and Disbursing Officer/Pension Payment Officer) (Office)
(Station)
I (Name, Designation and Office) hereby exercise my option to be covered under Employees Health Scheme and authorise deduction of Rs.........(in words...............) as my contribution towards Employees’ Health Scheme (EHS) from the salary/pension of December, 2013 payable in January, 2014 onwards at the rates prescribed in G.O.Ms.No.174, HM & FW (M2) Department, dated 01.11.2013 and subsequent orders that may be issued from time to time revising the premium.
OR
I (Name, Designation and Office) hereby declare that my spouse is a Government employee/pensioner and he/she is contributing for Employees Health Scheme (EHS) and a copy of undertaking given is enclosed.
To
The (Designation of the Drawing and Disbursing Officer/Pension Payment Officer) (Office)
(Station)
I (Name, Designation and Office) hereby exercise my option to be covered under Employees Health Scheme and authorise deduction of Rs.........(in words...............) as my contribution towards Employees’ Health Scheme (EHS) from the salary/pension of December, 2013 payable in January, 2014 onwards at the rates prescribed in G.O.Ms.No.174, HM & FW (M2) Department, dated 01.11.2013 and subsequent orders that may be issued from time to time revising the premium.
OR
I (Name, Designation and Office) hereby declare that my spouse is a Government employee/pensioner and he/she is contributing for Employees Health Scheme (EHS) and a copy of undertaking given is enclosed.
*( Strike whoever is not applicable)
Yours faithfully
