EAST COAST RAILWAY FAMILY DECLARATION FORM (For Privilege Pass/PTO) CARDEX No./Pass A/C No. NAME DESIGNATION OFFICE DATE OF APPOINTMENT DATE OF BIRTH P.F, AIC No. AADHAR No. RATE OF PAY (Grade Pay) SCALE OF PAY (Pay Band) CLASS OF PASS ENTITLED MOBILE No. OF EMPLOYEE (To be filled by Pass Issuing Authority) Ste (ig Namie oie any depo Relationship Age Date of Birth 1 2 - 3 4 5 ; - Signature of the employee Signature of the forwarding official Family Includes A (i). Spouse of Rallway Servant whether earning or not, (i) Sor/Sons below 21 years age and fully dependant on Railway Servant. (ii) Son/Sons of age 21 years and above who is a bonafied student of any recognized Institution (A. bonafied certificate in that respect is to be submitted at the beginning of the academic session further entitlement are as per Rule.2(d)(ii) of Railway Servants Pass Rule-1968, (iv) Son/Sons who is invalid irrespective of age. (v) Unmarried daughter of any age whether earning or not (vi) Windowllegally divorced daughter provided they are dependent on the Railway Servant,B. Dependants relatives (in case father is not alive) includes: (i) Mother/Divorced Mother (ii) Unmarried/widowed/Legally divorced sister. (ii) Brother/Step brother below 21 years of age provided he resides with and is wholly dependent on the Railway Servant. (iv) Brother of age 21 years and above who is a bonafied student of any recognized Institution. (¥) Brother/Step brother who is invalid irrespective of age. €. Dependants relatives in relation to widow appointed on compassionate ground will include Dependant widow mother of deceased Railway Employee. D. Incase the daughter is a Railway Employee, a corresponding debit shall be made in pass account of the daughter as well to extent of her own entitlement of pass as Railway Employee {Ref: A(V)}. E. A bonafied certificate in that respect is to be submitted at the beginning of the academic session {Ref: A(ii}. Further entitlement are as per Rule.2(D)(ii) of Railway Servant Pass Rule,-1986. F. Provided, that a person, shall be considered to be a dependant relative only if his/her income from all sources (including pension & deamess Relief) does not exceed Rs. 9000/- and Dearness Relief admissible to the pensionerifamily pensioner thereof rounded off to the nearest ten rupee figure or 15% of the basic pay per month of the Railway Servant whichever is more (Example: Rs.9000+Rs.360=9360 as on 01.01.2017 with DR@4%). DECLARATION I hereby declare that all the declarations given above are true. Further, none of the above persons declared as Dependant relative has a monthly income from all sources above Rs. 9000 + Applicable Deamess Relief or “15% of my basic pay per month’ in case of any declaration is found false at any stage, | would be liable for disciplinary action. Signature of Employee Counter signature of forwarding officer with sealNAME { Coast Railway gdiac teat / Es ‘tnt aren er tee tr ree a rtf fl rete et are Pee srry seg ret Fry ere 'DECLARATON FORM TO BE PRODUCED DULY FILLED IN BY THE RAILWAY EMPLOYEE AT THE TIME OF [ADMISSION THE RAILWAY HOSPITAL FOR THEMSELVES OR FOR THEIR FAMILY MEMBERS & OEPENOENT (ue crn ah tere ee one eg son 2 eee le re) (This Form should be tad in toto, other Ht will not be accepted) fein cd Gc) mt / Contra! Adms5109 ROQIELET NO, oor ‘ft ATH /Nome ofthe Patent 1 . ae $8. PRN VS! ne 4 BAFORA AF ROU ha ETA Ralaonshp of hepa ‘6 ed an Ga ae (a sad) 6 Name ofthe employee nhl Block capi). ~ fae /Father Name. = 7 oem ‘en Designation. Deparment sym erm SECO ns 1 Sea ated sna er oF awe omen Ge ST Whether running statiCasual about ODMOD nm PF Account No. wen ee rer en tee 2 Pies bh re et we ee (inet permanent Ty icasuelRe-employed ?ire-emloyed service wilterminate on 8. sree werarh ot ors seta emrctees @ ont eT Goeanaton of the immediate otce or suberdntesn-cnarge under whem employed 40. actual & firs ore area ara aftrarft on fee ariculer so the employee's Bil Comping OF C8 nny 14, fire Rent 4. ‘ascherd) af Praftest oft erréren Bi Uni No or sone Bato of apposimant of tne empioyes 42, fem are wed we aftr am fee Parveuias of bi passing Recounts tice . ce aren Pr seh Pore woh fe ee ee Br TE STV TET TE A HR AY ar eA nd ta re rch ew Fe ard nA A eR AA eT Sera aes a are feo | venga st rrém | Tneveby Gecare thal the above slalerentss correct and spree tothe recovery of Ue hospital cit charges as pac ieee tened iam my salary | sna be babe fo" any disciplinary ection i any discrepancy is detected in the above ‘deciaravon al any time tert en emer (7) / Signature of ne employee (ful). oe . ev tc emt eer 7 me ese fs He ree ed eee emt ah Age Pr swan ce era. an aT | ai as ine above enties and cemied thatthe patent is ented to get faces of Free Medical Atendance and ‘teatment m Paiway Hospitals and Heat Units ‘sredere ee ter Fee verted en eee “cree ge ets stored wn om eee Szpatuest ne Bi Consing Oicer wih Ofce Samp —_Sgralue ofthe Sub-Odnaesrcharge wih Oca Semp 43, seatth aah oem sae af arte gh a ota lngooe Regster No. sn Dial af AMIS on Date of ischarge sakes ate ate ad ee a er eee rece Fn tara ra face we 8 a | They Sos Str charge sl enue ate me fama ah stove Womaton uy ures snr Free on Fe Signature of Sstran-harge on dy signature of Doctor on duty or Sister-charge