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On a Hundred Rupee Stamp paper



The Form of Undertaking to be furnished by the person,

on whom the prospective Non-Earning Member is dependent

for discharge of liabilities to the Society.


The Chief Promoter/Secretary

______________________________________Co-op. Housing Society Ltd.,




Shri/Smt. / _____________________________________________________________________

had made an application for membership of the _________________________________ Co-operative

Housing Society Ltd., having address at
______________________________________________ _____________ He / She has no independent source of income and is dependent on me.I,
therefore, undertake the discharge all the liabilities, present and future, payable him/her admission to

membership of the society, on his/her behalf as communicated to me directly or though him/her
from time to time, by the Society. On failure of such discharge in respect of dues. I shall also be liable
for recovery u/s. 101 of the MCS Act, 1960, alongwith the said member who is dependent on me.

My details are given below :

(1) Name : ____________________________________________________________

(2) My address : ____________________________________________________________

(a) Office : _________________________________

(b) Residence : _________________________________

(c) Telephone No. : _________________________________

(3) Occupation : _________________________________

(4) Name & full address of the employer : _____________________________________________

(5) Monthly Income : _________________________________

Place : Yours faithfully,

Date :