Wbhs Annexure 5 Form Download New! May 2026

As per dated June 24, 2022, Annexure 5 is used to declare the income of non-working dependent beneficiaries.

The is a mandatory "Self Declaration of Income" document required for government employees and pensioners enrolled in the West Bengal Health Scheme (WBHS) . It is used to certify the monthly gross income of dependent family members to ensure they meet the eligibility criteria for medical benefits. Download WBHS Annexure 5 Form wbhs annexure 5 form download

Full name of the employee/pensioner, GPF No./PPO No., and residential address. As per dated June 24, 2022, Annexure 5

A solemn affirmation that the information provided is true. Be aware that suppression of facts can lead to disciplinary action under WBS (CCA) Rules, 1971 . Download WBHS Annexure 5 Form Full name of

List all eligible family members, including their relationship to the employee, Beneficiary ID , Aadhar Number , and Monthly Gross Income .

To complete the form accurately, you will need the following details:

After filling and signing, the physical copy must be submitted to your Head of Office (HoO) or Pension Sanctioning Authority (PSA). Why is it Important?