SELF DECLARATION REGARDING ONLY WIDOW

I, __________________, widow of late _____________________of Coast Guard

expired on _________________ the only wife of the deceased Govt servant who is not
survived either by any other widow (including a widow who has been judicially
separated from her husband) or by any minor child from the other wife.

Signature ___________________
W/o Late
Address: ____________________ 
______________________________ 
______________________________ 
Dated:

ATTESTED