Note: 1. Do not use carbon in filling up the claim forms

2. Forward the ink signed attested copy of Aadhar card

3. F~rward t_he copy of bank passbook in which your name and account

number Is mentioned

CHECK LIST

1. Your case needs to be taken up with Pension Sanctioning Authority (O/o the

JCDA (AF) , Subroto park, New Delhi - 10. It may be noted that this office is only the

processing agency and forward the claim forms to Pension Sanctioning Authority

(PSA) who in turn takes 1 to 2 months in finalization of the case. In case of any

discrepancy in the claim forms, the same will be intimated by the PSA only after 1 to

2 months. Hence, it may be clear to you that every error will cause 3 to 4

months delay in finalization of case. To avoid such delay and to ensure that

the forms are filled correctly before submission to this office. You are advised

to keep the following points in mind while filling up the claim forms :-

(a) Each and every columns are to be filled clearly in BLOCK CAPITALS

without any corrections or overwriting and no column is to be left blank.

(b) Passport size photograph showing the head and shoulders of the

claimant is required to be pasted (not to be pinned) on the first page of claim

forms in the space provided and the same should be attested by any serving

GAZETTED OFFICER and not any retired Gazetted Officer.

(c) Name is to be written which is recorded in the service record and the

same is written in the letter addressed to you. Bank account is to be opened

in the same name. Attach copy of first page of bank passbook.

(d) Attach ink signed attested copy of any proof of your date of birth . (i)

Aadhar card (ii) matriculation c:ertificate (iii) passport (iv) ECHS card (v)

Driving licence (vi) voter ID card (vii) PAN Card

(e) In column No. 10, if the claimant is NOT leading the communal life with

the Parents of the deceased air warrior and NOT willing to render financial

support to them, then the Family Pension may be divided between the two

parties. {in case of Special Family Pension (SFP) and Liberalised Family

Pension (LFP)}.

(f) In column No. 12 (a)(i) write the date of marriage as per service record

and the same is mentioned in the said column form ( in single copy) for Family

Pension forward by this Office for your ready reference. (in married cases

only)

(g) In column No. 13 (a) , write all particulars of children born out of the

deceased (name, date of birth and marital status) . Children details, as per

service record, are also mentioned in claim form for family pension (in single

copy) for your ready reference.

(h) In column No. 14, the details of your account number, the name of

bank, IFSC Code and full address with PIN CODE are required to be

mentioned. You are advised to open your bank account on anyone of the

nationalized bank or its branch in your district. (Further, please note that your

bank account number should not be changed/transferred till the finalisation of

the case.

U) In column No. 15, write your contact number and full residential . . ou are going to state permanently. After address with pin cod~ where Y. . han e in your residential submission of the claim forms 1f there is any c 9. . t .d address, the same may be informed immediately to this office O avoi any loss or delay.

(k) In column No. 16, write the particulars of person to whom the arrears of family pension are to be paid in case ot your demise.

(I) In column No. 17, put thE~ finger impression of your children below 25 years of age.

(m) In column No. 18 (a, b & c), write your name and put your signatu_re or thumb impression in the appropriate place . In addition , you have to put finger impression in the appropriate place mentioning the date.

(n) In column No. 20, obtain signature of 2 witnesses with their names and ensure that their full addresses are clearly mentioned .

(o) Get your claim forms attested from any of the signing authorities as mentioned on page No. 5 of claim forms after putting His / Her official stamp clearly showing his / her name , designation and the department in which he / she is serving .

(p) Attestation by the Principal / Headmasters of private colleges and schools are not acceptable .

(q) Marital status certificate, employment status certificate, income certificate and affidavit, if any, are to be submitted in original only.

(r) All certificates are to be submitted either in Hindi / English language only and should be either in original or duly ink signed and attested . Any vernacular version should be accompanied by and attested translation. (s) Attach affidavit on Non Judicial stamp paper duly sworn before Notary Public regarding Pending Enquiry Award (PEA).

NOTE: IN CASE IF YOU FACE ANY DIFFICULTY IN FILLING UP THE CLAIM FORMS, YOU ARE ADVISED TO APPROACH THE LAST UNIT OF YOUR DECEASED HUSBAND/SON/FATHER OR NEAREST ZILA SAINIK BOARD FOR ANY ASSIST ANGE / GUIDANCE. IN ADDITION YOU ARE WELCOME TO TAKE OUR ADVICE ON THIS MATTER. YOU ARE FURTHER ADVISED TO EXERCISE EXTRA CAUTION WHILE FILLING UP EACH AND EVERY COLUMN OF FAMILY PENSION CLAIM FORMS. DOUBTS REGARDING ANY COLUMN MAY BE CLARIFIED FROM THIS OFFICE. ANY MISTAKES IN YOUR FAMILY PENSION CLAIM FORMS WILL DELAY THE PROCESS OF SANCTION OF FAMILY PENSION BY 03 TO 04 MONTHS DUE TO AUDIT RELATED PROCEDURES AND OBJECTIONS.

! -

- 1io

f i

J;i f

. ~ ~! t

1¥ i ~ 1&

f ~ ~

I t§

I .!iJ fj

. f i!J

! litt

. i iilf

i !!it

f!il

~ t I ~ 1 l t ~

~ i ~

I ~ !

.~ ~ 1P ~ 1& 1¥ ~ A& lt .

I ~ ~-

~ ~ {

~ .g-. n:

I . 1

[ ~

V

. . ~

h-

~

L-

u.~

,tf,

JfZ ~

4&i-w

1Y ~

~

Iii l

~ .>

-'

,i= """4&crr.

~ ~

!t~j~

~·E

-i !!i ;~ :~~:

~~ "' ii-If:!'.'~ tt

i ~

19

., ~

«=

~

t, a;

f ~

; l i l; i ?,

~;

. ~ ~

t~ it

. .

.· t~t

:1& j

<[ . ~

'Ir-~

.··

~ '

~ $ i· ~ -1;;

tr ~

. g:

'W ~ .-

. ,i5-$ ~

;tr-.

i~

,ts-~dt

-.

~ tt

rg __ ~

~ ' 1&

f 'Ir-

. '

l I t'A,r, t

'Ir-~

jj; :::, ;;,

~

.

---~ i t:l ! t 1&

w

~ ! ~ 1 ~

~ii

~ ; 1

tl ~ 1& j i ·'I&

I;'.) l

if Ji;

i ~ .· 15

ll'

. %

,~~

w ~

:~

~

t! Ji r~""

11!1f1tl fr ~:1 €! [Ii ~1 €,,

. ('ii) "'"""'~ 15 4 jq,i ·~ 3l'PIT 'l[:(T f.f<rn,4 ~,:;:;:;:; ~~WTl~GTcrfffi~cffl-T~iITG~~q-ffi . 6T I

~c151;qfof.q~~cfRl~31NcITT~j,cf>'(1!.:, 31"2ffl~~ I

(~ ~~ 16~~~"$mG-ltfficnT~~~cZITTncnl" :f@"R~~.~~~~,

(c) cITTWr 13 ~ (cf)) ~ ~ "$ ~ ~ ~ · ~ ('1P1, ~ ~ 3itf ~cl I ffiq; ~~I

(o) cmwr~ 11 ~ 25 crct cfTT ~ ~ qi1, ~ ~ J,l1fc.t4'i ~ mtr t 1

~) cpfWf ~ 1 a (cf)), ~ ~ (1f) "$ '344cf>a ~ ~ · 3l"Cf"""'1T 6°f<:TT~ ;WfcfT ~ .:>

mtr wm)' I ~ ~~Rcfti, '34¥ci ~ ~ J;11fc.t~1 "$ m-q-~ ·g)rrr ~T ~ fc,j'{g--, I ffllTT I

(G) ctm¥f~20~Gl~~"ffifr~3llx~~fc?!l/s.-fl filln3W~~~ ~ ~ ffl ~ Gf l/s1 I 6lTTT I

("ff) Glq!"tJWTT~~~s~~~~m~~~'9".~GTcll' ffi, ~ fixcf>l{l ~ ('1 4jqlq,x, ~ ~ ~. ~ 3T\x fcrtrrT <pf cr$f m, ~q,xql41 .

(~ ~~ ~ ~m w ~ ~ ~ ~ C:-Rl lcl~l 'R ~ -~ xl\Jl4 ~a ~IDxr"~~6-RlT~ cf>-<qicf>x ffl~ cf>xq,4 1

(~ ~q I ffiq; ~f~nrnor tf-f, x'1--,t1 ii-< ~ >RlOf ~. 3-Wl wnor ~ 3-tR ~Ttr~ . .r~. ~ · -mm. ~ ~mfr l)- xIBRl" mr 1

(tf) ~~w:Trur~~ ~ ~ ~,jft-~ ~-g);,r 6ltTT l '3ct~~ffi~ ~cf Jffff ~ 3T~ ~ ~ "ffirr& 3fR ~,&-llifcna ct>xc11q-;x t 1 ~ ~ 'lWfi ~ mw m~ ~ ~6llfl' I

~ ~ 3TTtfcm ~ tnllIT "cfil" ~ ~ ~ ct,f61I~ 6T fil, ptfm '{-t5llkii 3TR lfflc';tq; ~ ~ 1'114'4il ~ ~ ifTt cfTT ~ ~ I ~ ~ffi" eyrr ~ ~ 1f~ q;ywr cfTT ~ ~ .-31fa R.cfc1 fl I cl 'tl 1..ft iffil, ~ m ~ ffi m-t 1R ~ cf> lll~C'I ll ~ ~ ~ W ~ ~ . fq~cf>xDi qRqf"R I "C!cf)'4,-~ffiIR 3TTW~~cfn"~~>ITTt3m~·3ltfey{~$ .~"$1"~6t~t1 . .

I CASE NOi-

Appendix "B" (Refers to AFO 243/77)

CLAIM FOR FAMILY PENSION

AFFIX YOUR RECENT

ATTESTED PHOTOGRAPH

7

(To be filled in BLOCK CAPITAL LETTERS in triplicate by the claimant for family pension &

return to Directorate of Air Veterans-Ill, Subroto Park, New Delhi - 11 O 01 O duly attested by the

authorised person, any one as mentioned in page no 5)

1 Service Number, Rank , Name & Initials of the deceased

2. Unit which last served

3. Name of the Claimant in full (In Block Capital Letters)

4 . Re lationship of the claimant with the : deceased

5 Marks of identification (one or two permanent marks of blemishes in case of female claimants,

which should be on the apparent parts of the body, such as hands, feet and face etc,)

6.

7 .

(a)

(b)

Date of Birth / Age of the claimant ( Mentioning date of birth is mandatory) Occupation of the claimant

_________ ./ _______ _

8. (a) If the claimant is already in receipt of remuneration from Public Revenues such as pay,

Pension , Provident Fund, Compensation etc, give the nature and details of employment or

number and dnte of Pension/ Payment_Order (PPO) notifying the award or amount of Provident

Fund compensation received as the case may be (Answer YES/ NO, if "Yes" give details) :-

(b) Has the claimant applied for the grant of another pension or allowances . If so give

particulars of that claim (in respect of the same deceased) . (Answer YES / NO, if "Yes" give

details) :-

9. Name of the Parents of deceased,

10. If the claimant is leading communal life with the Parents of the deceased's family and is willing

to contribute towards their supporting (Answer YES/ NO) :-

11 .

12.

Name of the Pension Disbursin Off (PD pension Mention TS/HO bg ice O) from where the deceased was drawing his · num er allotted by PDO :-

Further particulars regarding eligibility :-

(a)

(b)

( c)

(d)

If the claimant is widow :-

(i) _Whether she was married to the deceased by lawful and valid ceremony according the recognised customs? (Answer YES or NO) . State date of marriage -----(ii) Whether she has re-married since the death of her husband? (Answer YES or

NO)

(iii) If she has re-married :-

(aa) Whether re-marriage is with the real brother born to the same parents of her deceased husband or some other person . (Answer YES or NO)

(ab) Date of Marriage :

(ac) Name of second husband :

(ad) If the deceased has left behind more than one widow state their names and date of their marriages with deceased _____________ _ (if the deceased has left behind only the claimant , mention left behind only widow) .

If claimant is father :-

(i) Whether he is real (as distinct from step or foster) father of the deceased . (Answer YES or NO)

(ii) Whether he is a cripple or otherwise physically or mentally unable to support himself (the information is not necessary if the father is above 50 years of age)

(iii) Whether the widow and/ or mother of the deceased is are alive? (This information should be furnished if the father below 50 years of age)

If the claimant is Mother :-

(i) Whether she is the real (as distinct from step or foster) mother of the deceased? (Answer YES or NO).

(ii) Whether she is the re-married since the date of her son , so give details i.e., date of re-marriage -----------------If the claimant is Son or Daughter :-

(i) Whether he / she is the legitimate and real child of the deceased ? (Answer YES or NO)

(ii) In case of a daughter, whether she is married, if so state her date of marriage also

(iii) If Answer to ( i ) is negative , is he / she has the validity of an adopted child of the deceased ? Mention the date of Adoption : -------

13. (a) Particulars of the children of deceased : .

SL Name of children Date of Birth Soni Married or

No. dauahter unmarried

1.

2.

3.

4 .

5

(b) Are any of the children is in receipt of remuneration from Public Revenue such as Pay,

Pension etc. If so give details of employment for the Pension Payment Order PPO NO.

14. Name of Pension Disbursing Office (PDO) from where you would like to draw the Family

Pension . It should be a pension paying Treasury Office (TO) or Defence Pension Disbursing Office

(DPDO) or any Nationalised Bank of your locality of permanent address , which is authorised to

disburse Defence Family Pension . In case of Nationalised Bank, you may open an account, indicate

the name. branch, address and Code No. of the bank with your account No. (Account should be

Exclusively for family pension only)

I Account No I Paying Branch

BSR Code:

Main Branch

BSR Code:

15. Place of residence of claimant: House No / Name ---------------Village / Town Post Office

District State Pin

Tele No ___________ Fax No. --------

16- Particulars , ie .. Name, relationship and address of the person to whom the claimant desires to

pay the arrears of pension (on his I her demise)

17. THUMB ANO FINGER IMPRESSION OF THE CHILDREN BELOW 25 YEARS

SI Name Thumb No.

Index Middle Finger Finger

Ring Little Finger Finger

1.

2.

3.

4 .

5.

18. Name of the claimant --------------Signature or Thumb impression of the claimant :

THUMB AND FINGER IMPRESSION OF THE CLAIMANT

+ Thumb Index Middle Ring Little Date

Finger Finger Finger Finger

19. Name of the Legal Guardian : _______________ _

(Applicable in case of minor/mentally retarded claimant only)

Signature of the Legal Guardian : ______________ _

THUMB AND FINGER IMPRESSION OF THE LEGAL GUARDIAN

Thumb Index Middle Ring Little Date

Finger Finger Finger Finger

Note : In case of female claimant/ guardian right hand thumb and finger impression to be

affixed.

20. SIGNATURE OF WITNESS

Certified that the details furnished b a ove are correct to best of my knowledge:

1. Signature or Thumb impression

Name and address of first witness

2. Signature or Thumb impression

Name & address of second witness

ATTESTATION

Certified that to the best of my knowledge and belief, the particulars given ir, respect of Smt/ Sri

/ Miss / Master _______________ widow/ mother/ father/ son / daughter of the

deceased are correct. (Give the name and relation of the claimant to the deceased).

Place :

Date

COUNTERSIGNED

Signature Name & Designation With office seal

Place : Dte of Air Veterans , Air Force

Date

The attestation may be completed by any one of the following :

(i) Sarpanch / Pradhan of Village / Village President / Village Officer.

(ii) Any serving or retired gazetted officer Civil or military, not below the rank of

JCOM/O.

(iii) Post Master / Sub Post Master.

(iv) Patwari.

(v) Sub Inspector of Police.

(vi) A member of Municipal Corporation I Zilla Parisad Board etc .

(vi i) Panchayat Executive Officer.

(viii) MP/ MLA.

(ix) Oath Commissioner I Notary Public

ANNEXURE 'C'

S lalcmc-nt of hi ghc-s t r:rnking t·ligiblc mt•mhcr of the fomil y tht· dt·t·cast·d.

~E l{ V IC[ .~ O. i llAN h: - -- - - ---- -- -- -- - -

:\A .\1 E

li\ lT

I . :\'amc of t ht· C laimant

.2 . Rl'l a tio ns hip "ith tkn·ast•d

J .

5.

Agc/ D:llt' o f Uirth

Da t1.· of Bi r th ( if the person is thc

Bro th1.·r of th1.· de1.·t•asl'd)

\\' h1.·th1.·r married/unmarried/

"ido" (if thl' pc·r sun is daughter/ s t1.·p d ~t ugh ll'r/s is tcr/s tep sister).

(b ) If answl'r to (a) above is

~l a rried/ wid ow, date of marriage/ Wid u\, hood.

C A SE NO

6. :\am1.·, agl'. rl'latiunship etc of the other members of the fami ly o f the deceased eligible (lis t at

the end ) for Death-C um-Retirement-Gratuity.

SI !\' o ~a me & Initials Relationship With the Deceased

S tatio n :

Date of Age In case of birth D,1ughter /sister

M.i r tial status

Sig1rnlurc or kft/Uig ht* Hand thumb impress ion of the claimant

'o\

-2-

Signature of two witnesses: -

I.

2. (N:,mr and address in block capit.al letters)

ATTESTATION

Certified that the best of my knowledge and belief the particulars given in respect of

Mrs/Miss/Mr ........................................... Wife/Mother/Father/Son/Daughter of the deceased are correct~Give the name and relation of the claimant of the deceased).

Place: (signature)

Date: Name and designation with office seal

COUNTERSIGNED

Directorate of Air Veterans

Date:

The attestation may be completed by any one of the following: -

(a) Sarpanch/Gram Pradhan (b) Any serving or retired officer, civil/military (c) Sub Post Master/Post Mast.er (d) Patwari (e) Sub Inspector of Police ( SI) (f) A member of Municipal Corp/Zilla Parishad Board etc. (g) Panchayat, executive officer (h) MP/MLA (i) Oath commissioner/Notary public

PART II

( Gp Capt/Wg Cdr/Sqn Ldr .JD AV - Ill (FP) Directorate of Air Veterans

(For use by Defence Accounts Department to record particulars of award granted as

shown below). Death Cum Retirement Gratuity amounting to Rs .................... ....... (Rupees ............................................................... } Sanctioned vide PPO 08/14/8/F/P/ ...................................... .

Accounts Officer(Pension)

FO RI\ I TO BE CO l\ ll'LETED FOR Tl-I E GRAN T OF

DEAT H CllM IU'.Tlll. EMENT GRAT UITY/R ESID UA L GRATUITY

TO THE FAMILY OF DECEASED AIRMAN

-- - -- ---- - -- -- - - --'

I. ~F: R\'I CE NO. I

~--- --- ---- ----- --

J . :'-i AM E

7. ~:111u.· of the C laimant

8. Rl·latio nship with dl'l'l'llsed

9. Identificat ion marks

(One or two permanent marks of blemishes

on the apparent parts of the body each on

hands, feet's etc may be recorded)

10. Age/ Date of Birth

11. Account '.'lo & Name of the Bank/Treasury

at which pa y ment is desired.

12. F ull address of the claimant showing village,

T chs il , District , i111d s tate.

13. • Rig ht /left hand thumb and four fingers

impression of the claimant.

1-t. If the claimant is minor, Name and

relations hip of the guardian.

15. • Right/ left hand thumb and four

fingers impress ion of the guardian.

Station

In rnse of female claimant

(I.e. , Right hand)

2. RANK

"· Tntdl·

6. CASE NO

··· ······•·· ·•·······N ········ · ·········• •·• ······ •i ; __ ,_

Signature or left/Right"

ANNEXURE 'D'

Dall· H:1nd thuml> impression of the claimant

-2-

Signature of two witnesses: -

I.

2. (Name irnd address in block capital lett.ers)

ATTESTATION

Certified that the best of my knowledge and belief the particulars given in respect of

Mrs/Miss/Mr ........................................... Wifc/Mother/Father/Son/Daughter of the

deceased are correct(Give the name and relation of the claimant of the deceased).

Place: (signature)

Date: Name and designation with office seal

COUNTERSIGNED

Directorate of Air Veterans

Date:

The attestation may he complet.ed by any one of the following: •·

(j) Sarpanch/Gram Pradhan (k) Any serving or retired officer, civil/milit.ary (I) Sub Post Master/Post Master (m) Patwari (n) Sub Inspector of Police ( SI) (o) A member of Municipal Corp/Zilla Parishad Board etc.

(p) Panchayat, executive officer (q) MP/MLA (r) Oath commissioner/Notary public

PART II

( )

Gp Capt/Wg Cdr/Sqn Ldr .JD AV - Ill (FP) Directorate of Air Veterans

(For use by Defence Accounts Department to record particulars of award granted as

shown below). Death Cum Retirement Gratuity amounting to Rs ........................... (Rupees

............................................................... ) Sanctioned vide PPO

08/14/B/F/P/ ...................................... .

Accounts Officer(Pension)

(TO BE GIVEN ON Rs. 10/ NON JUDICIAL STAMP PAPER)

LETTER OF UNDERTAKING Principal Director Directorate of Air Veterans Air Headquarters Subroto Park, New Delhi - 110010

Dear Sir,

Payment of Pending Enquiry Award (PEA) or any other amount/benefits accruing as a consequence of Air Force Service

In consideration of your having at my request agreed to make payment of Pending Enquiry Award (Prior to finalisation of family pension) or any other amount/benefits accruing as a consequence of Air Force Service of my husband/father/son, I, the undersigned, agree and undertake to refund or make good any amount to which I am not entitled or any amount which may be paid to me in excess of the amount to which I am or would be entitled. I further hereby undertake and agree to bind myself and my heirs, successors, executers and administrators to indemnity the Air Force/Government of India from and against any loss suffered or incurred by the Air Force/Government of India in so paying the Pending Enquiry Award or any other amounts/benefits to me and to forthwith pay the same to the Air Force/Government of India and also irrevocably authorise the Air Force/Government of India to recover the amount by debit to my pension account or any other amount/deposits belonging to me in the possession of any bank/PDO!freasury Office or any other financial institution or to adjust the same against any pension or other benefits payable to me or accruing to me in future.

Date:

Place:

Witnesses

1 . Signature Address:

2. Signature Address:

Yours faithfully,

Signature:

Name

Address

(TO BE ATTESTED BY NOTARY PUBLIC)

Note:- The income certificate is required for each financial year separately with effect from death / disqualification of previous pensioner

INCOME CERTIFICATE / INCOME DECLARATION (As per Para (II) of Gol MoD No. 1(3)199/D(Pen/Sers) dt 24.11 .99)

I, ... ... . ... .. ... .. .... ... ... ... ... .... ..... .. .. .. ... ... .. . ... .. . .. . ... .. ... . ... ....... .. ... .. ... .. (Name of

the applicant) ....... .. .. . .... . . ... ..... .. ....... .. ... .. . (wife/husband/son/daughter/father/mother) of

No . ... .... ... .. .... .. .... . Name .. .. ... .. ... .... .. ... .. ... . ... .. . .... ....... . .. . .... Rank ..... ... .. ............... ,

resident of

.... ........ ... ... .... ..... ........ . ... ... ..... ... . ..... do hereby solemnly affirm and declare as under:-

Source of the annual Income For the year .... ... .. .. ......... ..

(a)

(b)

(c)

(d)

Income from immovable property

Income from Moveable property

Income from Employment (Pvt/Govt)

Income from pension

Rs ... ........ ...... ... .. ... ..... .

Rs ..... ... ....... ........... .... .

Rs ...... ................. ... .... .

Rs ... ..... .. ... ..... ....... .. ... .

(e) Income from self employment/business Rs ............. ..... ............. ..

(f) Income from other sources

Place :

Office seal

(Name of Sources should must be mentioned)

Rs ... ...... ......... .... .......... .

Total

ATTESTATION

Rs .................................... .

Signature I Thumb impression of the applicant

(By Village officer I Municipal CouncllorJ

COUNTERSIGNED (Bv Tehsl(dar I Revenue Magistrate)

\

AFFIDAVIT

1,........ . ....................... . (N ,·1111 1°' ..... ... '.'.... ......... '-- of the applicant)

Wile/Husband/Son/Mother/Father of Shri o O o o o O O O Io o o O ♦ 0 o O O o O O o Io oo o o o o I o o 0 0000

Aged .......... years, resident or ........... . .. . ............. ..... ............ do hereby

sole111nly affirm and declared as under :-

The deceased .............................. .. .... . ....... .. .......... (Name of the

deceased service personnel) was my son/daughter/brother/sister.

I was wholly dependent upon my late son/daughter/brother/sister mentioned

above, for pecuniary needs.

DEPONENT

VERIFICATION

I the above said ..... .......... .. ..................... . (Name of applicant), do hereby ,

solemnly affirm and declare that the facts mentioned above are true to the best or my

knowledge and belief and nothing has been concealed thereof'.

DEPONENT

PLACE:

DATE :

ATTESTED BY 1·'ff CLASS MAGISTRATE

PAY & PENSION CERTIFICATE

I .... . .. .. .. .. ..... ..... ...... .... ... ... . ... ... .. Father/Mother of Ser No ... .. ... .... .... .. .. .... ... Rank ...... .. ....... ... .

Nam e .... .. .. .... ..... ............ ..... is /not in receipt of any Pay or pension from any public/Govt resources .

I am serving/not serving in Govt Offices . I am umemployed/Employed in ... ... .... ... ..... ... .. ..... .. .. .. ... and

get Rs ......................... . as salary.

Date : Signed by any gazetted officer mentioned below

The attestation may be completed by any one of the following : -

(a) Sarpanch/Gram Pradhan (b)

(c) (d )

(e) (f) (g)

(h} (i)

Any serving or retired officer, civil/military

Sub Post Master/Post Master Patwari Sub Inspector of Police ( SI) A member of Municipal Corp/Zilla Parishad Board etc.

Panchayat, executive officer

MP/MLA Oath commissioner/Notary public

\ BACHELOR CERTIFICATE

This is to certify that Late Ser I\Jo . Rank Name

is S/o of (Father) and

........ .... ... .. ............... . .... ........... (Mother) who are res ident of

······· ··· ···· ··· ········ ·· ········ ············ ·· ··· ·· ······ ·········· ····· ··· ····· ····· ···· ········ ·· ·········· ···· ··· ··· ··· ······· ······ ··· ··

Died on .... .... ... .. ... . and he was unmarried at the time of death .

Date: Signed by any gazetted officer mentioned below

The attestation may be completed by any one of the following : -

(a) Sarpanch/Gram Pradhan (b) Any serving or retired officer, civil/military (c) Sub Post Master/Post Master (d) Patwari (e) Sub Inspector of Police ( SI) (fl A member of Municipal Corp/Zilla Parishad Board etc. (g) Panchayat, executive officer (h) MP/MLA (i) Oath commissioner/Notary public

FORMAT 'H' FAMILY DETAILS

Full Family details of Ex Army No. _____ Rank ___ Name __________ _ Records: ______ _

. (A) Details of Marriage/ Re-Marriage (Widows):-

SI Name of Widows Age/ Date of Date of Date of

No. Date of Birth Marriage Divorced Death

(i) (ii}

(B} Details of all children born out from deceased : -

SI Name Male/ Mother's Age/ Date Date of Date of Date of No. Female Name of Birth Marriage Widow/ Employment/

Divorced Death (i)

(ii)

Oii)

(iv)

(v)

(vi)

(vii)

(C) Details of Parents of deceased :-

SI Parents Name of Status of Real Age/ Date of Employed/ No. Parents / Foster /Step Date of Birth · Death Pensioner

'i) \I (ii)

(D) Details of Brothers and Sisters of deceased : -

SI Brother I Name of Brother / Sister Age/ Date of Date of Date of Death No. Sister Birth Marriage / Employment

(i) (ii)

Signature of Claimant

ATTESTATION

By Sarpanch I Gram Pradhan I Municipal Councilor or Any Officer, who competent to do so