!

tNq{EXtrL'E 'C ''

irstails cf CepenUent family members uhosc ni..mEs are notccFr,rm-1
crn

ur-rr,Lyfiule S+if 2i ;f CCs(F,"nsi,:n) iiule '8f i. tt. nut shuun in

.l-*"s es famiiy member in term Li kuLe-4(u) of CtS(LIg) tuule s'tl8.
-o -. -o -o -l -a-o -o-o -. -. -r -a -o -o -t -a -t-r -a
-l -o -. -l -o-t -a -r -a-o -t

lji,rnc r,f the vt. scrvint G(

Lrieignrtir:n & A/C No. z

Lnte .f rpl-)Lintmcnt '.

_
e -o -r -- o -a -o -r -r -. -r -a -a -r a r -o -a - o _r a- o- r -t -t
-t -o -l -e -o -. -

r--tii-'i-1s Lf the mumEcte of my farnily as.'n 2-

_o _': _o
t -. -t -a -r -t -t -t - t -. -o -o
-o-l -a -o -t -a -o -a -

g1. Ni.mc c:f Lhe riembcrs iJ.'lte Lf i(eli't-ir,nship Initiel

lrirth uith thc .-'f thc
I,lL.. lamilv
.--'i;f Remerks
cf itc,_;r. l-lcrcl cf af f ice.
_t _o -o-
-a e - a- o -a -a -a -! -o -a -t -a -'o -, - o -l -o -o
aaaaaa -a -o -r -r -r-

1.
a
Zt
?

1] .
q

6.
.aaoaat"'

I h*reby undErtnkc ti.r keep the abiive ire rtr cuI. r s upto d"'ttr by
n.- tif ying tu the r.udit tifficur,/htjctl cf uFfice mcy adciticn cr alturr-
tit;n.
I algo hereby unLcrtake thct the family memhLrs uhose nmeca iiru
muntiufiaL abuve ere uhully dcpr:ndunt Upan mu dnC j'ncome af elch
l'tr-fib r f rom all sources icus not cxccclls [is.15iCl- i]er month.

Flun se a
a

f - |-. a
L/ LL a

Sign:',turc cf Govt.. Servi'nt

_o -a -a-o -r -r -a-a]a -1.-, -o -. -r -
-l -o -l -t-t -a -e -a -l-o -o -o -l -o -o -o-l -a -l-r

Ngtet- Family for ths purpcsc.,l LTC mcens(ExcLuCing thc nemes of

familY membcrs shoun is Fr,rm 3 ).
i ) Unm,rried chil.drcn i r str;p chilcJren c f iiqJ6 25 Yee rs mnd rbove
nr.i uholly depenient cn the 6nvi:rnment SCfvi-ntS.
ii) M; rrieC claughters L,ho hevc bc;n tJivcrccd' ertlent-,snecl nr scpalfited
f rr:m thcir husb.ngs anr: are iursiding LJith tho Gcvtr scrvt nt tinc eri-
cn the Govt. sErv,,it.
"n.'irv';;;";Junt
ii i) Fa rents anc/;r etGF, m;nthcx rEsic'lng ui th cnLl uholly dcpcncent
on bbe Govtr gerv-;t'it.
iv) Unmi:rriud minor brotherS as L;elI as unmcrr'i';C, clivcrcudr i:bandenerj
rr sicing r'lith anc
scr.,erFlcc f rr-m thlir l'tusbF ncs rjr uli.lt'uel' sistt,rs tirair
depenceni;;-thc Gr:vt. sorv+;nts Irrrvitjsd ptrrent6.r''rli
"ni.1iy
uitht r not.alivc ot rinc themselvc uhcily Ci;pcndcnt cn the Gcvt' suxvr:Ftr
NIvl. 1 5-t 4-L7. ,L