FORM 14 (See Rule 77 (3) and 81 (2) ) FORM OF APPLICATION FOR THE GRANT OF FAMILY PENSION, 1964 ON THE DEATH OF A GOVERNMENT SERVANT/PENSIONER. 1. Name of the applicant .................... (i) Widow / Widower .................... (ii) Guardian if the deceased pension is survived by child or children ........................ 2. Name and age of surviving widow/widower and children of the deceased Government servant /pensioner ................... 3. Name and No. of the P.P.O of the : ........................ deceased pensioner 4. Date of death of the Government : ........................ servant / pensioner 5. Office / Department / Ministry in which : ........................ the deceased Government servant / pensioner served last 6. if the applicant is guardian , his date : ........................ of birth and relationship with the deceased Government servant / pensioner 6.(A) If the applicant is a widow / widower : ........................ the amount of service pension which she / he may be in receipt on the date of date of the husband / wife. 7. Full address of the applicant : ......................... Sl. Name Relationship with Date of birth by No. the deceased Christian era person .................... .................... .................... 8. Place of payment of pension and : ................... Gratuity and (Treasury, Sub-Treasury of Public Sector Bank Branch and pay and Accounts Office) Contd.P/2 Page - 2- Enclosures : (i) Two specimen signatures of the applicant duly attested (To be furnished in two separate shoots). (ii) Two copies of passport size photograph of the applicant duly attested. (iii) Two slips each bearing left hand thumb and finger impression of the applicant, duly attested. (iv) Descriptive Ro1 of the applicant, duly attested, indicating (a) height and (b) personal marks, if any, on the head, face, etc. (Specify a few conspicuous marks, not less than two, if possible). (To be furnished in duplicate). (v) Certificate(s) of age (in original with two attested copies) showing the dates of birth of the children. The certificate should be from the Municipal Authorities or from the local Panchayat or from the head of a recognized school if the child is studying in such schools. (This information should be furnished in respect of such child or children, the particulars of whose date of birth are not available with the Head of Office.) 9. Indicate whether family pension is : ................... admissible from any other source-Military or State Government and/or a public sector undertaking / authonomous body / local fund under the Central or a State Government. 10. Signature or left hand thumb-: ................... impression of the applicant. 11. Attested by : Name Full Address Signature (i) .............. ............. .......... .............. .............. ............... (ii)............ .............. .......... .............. .............. ............... 13. Witnesses : Name Full Address Signature (i) .............. ............. .......... .............. .............. ............... (ii)............ .............. .......... .............. .............. ............... NOTE: Attested should be done by two Gazetted Government servants or two or more persons of respectability in the town, village or pargana in which the applicant resides.
