ANNEXURE – II

FORM OF APPLICATION
Application for a Family pension for the family of late Shri / Smt ............................................................

Designation .................................. in the Office / Department of……………………………………….

1. Name of Applicant
2. Relationship to the deceased Govt. servant / Pensioner
3. Date of death of the Govt. servant / Pensioner
4. Date of retirement, if deceased was a pensioner
5. Name and ages of surviving kindred of the deceased

Name Date of Birth

(by Christian era)
Widow / Widower

Son

Unmarried Daughters

Parents

6. Name of the Treasury / Sub-Treasury at which payment is desired

7. Signature of left hand Thumb impression :

(In case of those who are not literate enough to sign their name)

8. Descriptive roll of ................................................ widow /widower / guardian of the minor children / parents
of Late .................................. ……………………………………………. Ex- …………………………………
(i) Date of Birth …………………….. (ii) Height ……………………….
(iii) Personal marks, if any, on hand or face ………………………………………………………………
(iv) Left hand thumb and finger impressions

Small Finger Ring Finger Middle Finger Index Finger Thumb

Attested by – Witness

(1) __________________________________ (1) _______________________________________

(2) __________________________________ (2) _______________________________________

Note : The Descriptive Roll (column 8) and signature or left hand thumb and finger impressions accompanying application for family pension should be in duplicate (in two separate
sheets and attested by two gazette officers in presence of respectable person in the town, village or pargana in which the applicant reside.)