SOUTH EAST CENTRAL RAILWAY

FAMILY DECLARATION FOR PASS (SERVING EMPLOYEES)

(To be submitted in duplicate)
Bill Unit No. : ……………………..

Name of the Employee………………………………………………Son /daughter of Mr. Mrs.…………..

PF/NPS No.

1. I solemnly declare hereby that as indicated below are my family members

residing with me and are wholly dependent on me. In case any addition or
alteration arises I shall submit a fresh family Pass declaration in the
prescribed form again.
Metal Pass/Card Pass on hand, if any No.

Family No. Relationship Age Date of Birth

(Compulsory)
My
i father is not alive /missing Wifefor/Husband
more than 7 years and his where above are not known
(affidavit
ii enclosed) U/M Daughter/Step/adopted
N.
iiiB. 1. Please strike out which
U/Mis/are/not
Daughter,applicable
widow
2. Proof
iv for date of birth is to be attached.
Legally divorced daughter
3. Certificate
v of studentship inSon/Step
prescribed format is to be attached.
/Adopted
son under 21 yrs of age
ii
iii
iv
Ii Solemnly
Son /Step/ Adopted son above declar
21 yrs if Bonafide student* or invalid
ii
iii
iv
My dependent Relatives are as indicated below
Widow /Mother/Step mother adoptive
Mother
Unmarried /widow/Sister Step sister
and legally divorced sister/stepsister
Brother/step brother under 21 yrs of
age
Brother /step brother above 21 yrs of
age if bonafide student *or invalid
dependent on me and is /are residing with me and do not have independent income ## (from all
source including pension ) more than 15% of may emoluments or Rs 2385/= *PM whichever is
more.

Station.

Date. Signature of the Employee

PRESENT RESIDENTIAL ADDRESS
(V)
House/ Qrs. No, Rly. Govt. Pvt. Name in full
Street/ Mohalla Designation
Post office Station
Taluka /Dist./State Basic Pay

Date of birth
Date of Apptt.

Permanent Residential Address:

House/Qrs. No.
Street /Mohalla
Post Office
Taluka/Dist./State
Pin
Note : For medical facility in addition to above family members.
i) Sons above 21 years of age but wholly dependent.
ii) On and reside with railway employee.

Date Signature of the Employee

## As Proof for dependent’s income, relevant certificate from competent authority/pension

payment authority is to be enclosed.
 Variable time to time as prescribed by Railway Board.
No. Date

forwarded to for record in the pass register for future guidance

Office Seal Signature of the forwarding

office with Seal