HOuse RENT ALLOWANCE (H.R.A.
) DECLARATION
As on 1st January/July ..................... (Year)
(Go. No. 97SE(B), Dt-07.03.2001)
(As Per ROPA-2019 [Link]. 437-SE(P&B)SL/5S-408/19,Date:13-12-2019, of S.E. Dept.,WB)
PART-A (To Be Filled By The Employee)
I am Married/Unmarried/Widow/Widower/Divorcee: (Strike out which is not applicable)
1. Name of the Office/School:…………………………………………………....……………………………………………………………………
2. Name of the Employee: ……………………………………………….....…………………………………………………………………………..
3. Designation of the Employee: ……………………………….....………….Employee Code : ..…………………………………………
4. Date of Joining : ................................D.I./S.(S.E.) Approval Memo No. : ...........................................................
5. Date of Birth : .................................... PAN No. : .................................... Aadhaar No. : .....................................
6. Marital Status :……………………………………… If Married Date of Marriage : ………………………………………………………
7. Employees' Present Basic Pay as on January/July, 20 (Band Pay+Grade Pay): ......................................
a) Employees'Present H.R.A. as on January/July, 20 :........................................................................
b) Opted for Swasthyassathi? Yes /No
c) Whether you get Swasthyassathi Card? Yes/No
If, Yes then write the no. of Card………………………………………………………………………………………………
I do hereby declare that the above details furnished by me in ‘PART A’ are true & correct to the best of my
knowledge.
…………………………………………………………………
Date: ………………………………………
Full Signature of Employee
PART-B (To Be Filled By The Spouse)
My Wife/Husband is/was not in Service /Unemplyeed under the Government of India or any Other State
Govt. or Govt. undertaking or any Statutory / Local Body / Educational Institute / Autonomous Public Undertaking
(Strike out which is not applicable) Or,
My Wife/Husband is/was in Service and following are the particulars of Her/ His employment and
Pay Allowance etc. drawn by her/him: (Strike out which is not applicable)
a) Name of the Spouse: …………………………………………………………………………………………………………………….
b) Name of the Office/ School :…………………………………………….…………………………………………………………
c) Full Postal Address of the Office:………………………………………………………………………………...................
……………………………………………………………………………………………………………………PIN………………………
d) PAN : ........................................................................... Aadhaar No. : .............................................
e) Spouse’s Present Basic Pay as on January /July, 20 (Band Pay+Grade Pay):…………………………...
f) Spouse’s Present H.R.A. as on January / July, 20 :..………………………………………………………………….
g) Whether spouse is opted for Govt. Housing:………………Housing Schame Name : ………………………………..
h) Whether spouse opted for any Govt. Health Scheme: ……………………………………………………………….
i) Whether spouse opted for under Swasthyassathi Scheme: Yes/No
I do hereby declare that the above details furnished by me in PART-B are true & correct to the best of my
knowledge.
Date: …………………………………………………….
Enclosed: Salary Certificate of Spouse.
…………………………………………………………………
Verified by Full Signature of Spouse
…………………………………………………………………..
Signature of Head of Institution with Seal & Date