FORM No, 6 (Pension/NPS)

of
Statemnent showing the details of the members of the family for purpose
Family Pension Scheme-1964/Appointed on or after 01,01.2004
Name (Block Letters)
Father's/Husband's Name
Branch: Office:
Designation
Date of Birth :
Date of Appointment:

Detaiis of Family a affixed against each name)

(Pass Port Size Photograph of each Family members to be
Two
Date of Birth Pass Port size
Relationship Identification
Srl.
Name with the Rly. (by Christian marks of each Photo
No. Servant era) & Ref. members

contd-p2
 belief and
are true and correct to the best of my particulars
given
that the particulars under RS (D&A) Rules
1968 for any
I do hereby declare for Disciplinary action
knowledge and I will be liable consequences.
later on as will asI will be responsible for itsRSCR-1966 regarding marriage.
found false not violated Rule-21 of
have
Ialso declare that I
applicable)
*(Strike out where it is not
Signature of the Employee

Station:
Dated:
Full name (Block Letters)
Designation
Office/Deptt.
EMP No./PRAN No.

WITNESS
Countersigned Signature with Date
Name (Block Letters)
Designation
office/Deptt.

DECLARATION OF SPOUSE
are true and correct
hereby declare that particulars furnished above by my Husband/Wife
Ido
knowledge.
to the best of mny belief and

WITNESS
Signature/LTI of Spouse

Name of the Spouse Smt.

Signature
(Block Letters):
Signature of the Employee:
Name (Block Letters)
Designation
Office/Deptt.
Emp. No. /PRAN No.

Countersigned

*(Strike out where it is not application)

Station: KHARAGPUR
Date
Head of Office/Acco unts Officer