APPLICATION FORM FOR OLD AGE PENSION FOR THE AGE OF 65 YEARS AND ABOVE (CENTRAL) TO BE FILLED UP BY THE APPLICANT 1. District __________________ Block/Municipality _______________________________ Village/Panchayat/Monilla/House No. _________________________________________ 2. Shri/Smt : _________________________________________ 3. Name of Father/Husband : _________________________________________ 4. Full Address : _________________________________________ 5. Categories/ST/SC/Women/ Landless/Handicapped/General : _________________________________________ 6. Age on date of application : _________________________________________ 7. Identification mark : _________________________________________ 8. I do solemnly affirm that : i) I do not have family income of Rs. 5000/- per annum or more. ii) I have/have not applied previously for grant of old age pension under NSAP. iii) I am resident of ________________ district/state where I have been residing during the three years immediately before the date of application. iv) I declare that the information furnished in the application is true and correct to the best of my knowledge and belief. Place : Signature of thumb impression of the applicant Result of preliminary enquiry by the village level team : (Head GaonBura and senior most teacher/supervisor/EO/SA) 1. Age : _________________________________________ 2. Income/Destitution : _________________________________________ 3. Category/Domicile : _________________________________________ 4. Whether applying for the first time : _________________________________________ if not, the decision on the last application : _____________________________________ 5. Recommendation : _________________________________________ Dated : __________________ Signature of verifying person at the village level Name 1. 2. Address : Note : This application should be sent with full particulars to the CO/EAC concerned. Date : Recommendation of the CO/EAC Signature of CO/EAC
