For spousal living donor (to be filled by competent authority* and Authorisation Committee, of the hospital or district or state in case of foreigners) [See rule 18(2)]

I, Dr./Mr./Mrs/Miss.................................................................. possessing qualification of ..................................... registered as medical practitioner at serial No. .........................................by the ......................................................................................Medical Council, certify that:- Mr........................................................................S/o................................................................................aged..........................resident of ............................................................................................. and Mrs..............................................D/o, W/o...........................................................................aged.......................resident of......................................................................................are related to each other as spouse according to the statement given by them and their statement has been confirmed by means of following evidence before effecting the organ removal from the body of the said Shri/Smt/........................................................................(Applicable only in the cases where considered necessary). OR In case the Clinical condition of Shri/Smt........................................................... mentioned above is such that recording of his/her statement is not practicable, reliance will be placed on the documentary evidence(s). (mention documentary evidence(s) here)....................................................................................................................... a. Marriage certificate indicate date of marriage b. Marriage photographs c. Date when transplantation was advised by the hospital ( to be compared with duration of marriage): d. Number and age of children and their birth certificates e. Any other document Signature of competent authority */Authorisation committee in case of foreigners along with Seal/Stamp Place ..................................... Date...................................... *Director or Medical Superintendent or In Charge of the hospital or the internal committee of the hospital formed for the purpose.as defined under the rules of Transplantation of Human Organ Act, 1994(42 of 1994).