APPLICATION FOR THE GRANT OF FAMILY PENSION ON THE DEATH OF PENSIONER

1. Name of the Applicant : (i) Widow / Widower : (ii) Guardian (if the deceased person is : survived by minor child or minor children) 2. Name and age of surviving widow / widower : and children of the deceased Government servant / pensioner
______________________________________________________________________________________________ Sr. No. Name Relationship with Date of Birth in deceased pensioner Christian era ---------------------------------------------------------------------------------------------------------------------------------------------
1. 2. 3. 4. ----------------------------------------------------------------------------------------------------------------------------------------------
3. Name of the deceased pensioner : 4. PPO No. : 5. Date of death of the Government servant / pensioner : 6. Office / Department / Ministry in which the deceased
Government servant / pensioner served last 7. If the applicant is a guardian, date of birth or minor and relationship with the deceased Government servant / pensioner : 8. If the applicant is a widow / widower the amount of service pension which she / he may be in receipt on the date of death of the husband / wife: 9. Full address of the applicant: 10. Place of payment of pension and gratuity (Public Sector Bank Branch & Pay Accounts Office): 11. Signature or left hand thumb impression of the applicant*: 12. Attested by : Name ________________________ Signature ___________________ Full address ________________ 13. Witnesses : (i) ________________________ (ii) ________________________
ENCLOSURES : 1. Two specimen signatures of the applicant or left hand thumb: impression* duly attested. (To be furnished in two separate sheets) 2. Two copies of passport size photograph of the applicant, duly attested. 3. Descriptive roll of the applicant duly attested in duplicate indicating height and personal marks,
if any, on the hand, face etc. (Specify atleast two conspicuous marks) 4. Certificate(s) of age, two attested copies, showing the dates of birth of the children. The certificate should be from the Municipal Authorities or from the local panchayat or from the head of a recognized school if the child is studying in such school. (This information should be furnished in respect of such child or children the particulars of whose date of birth are not available with the Head Office). NOTE: Attestation should be done by two Gazeted Government Officials or two or more persons of respectability in the town, village or paragana in which the applicant resides. In case of re-marriage of the widow while applying for family pension on behalf of minor child, the widow should furnish the date of her remarriage, the branch of the Public Sector Bank at which payment is desired and her full address in the application for family pension. It is not necessary to furnish a fresh application or the documents as they are already available with the pension papers on which family pension was originally admitted to her. * In case the applicant is not literate enough to sign his / her name.