FORM 52-A

[ See Chapter XXI, para 529-A, rule 8 ]

( To be printed on foolscap quarto )

Half-yearly declaration of female pensioners whose pensions are terminable on their marriage.

(This certificate is to be attached to the pension bills for December and June).

Pension Payment Order No. _____________________

I, hereby, declare that I am not married and that I have not been married during the past half-year

Widow	of the late _________________________________________________________
Daughter
Dated____________19 .
To be signed by two responsible Officers or well-known persons.		We certify to the best our knowledge and belief that the above declaration is correct.
(Signature)
(Designation)
(Signature)
(Designation)
Dated______19 .