Appendix 'E' REGISTRATION FORM-WIDOWS/WAR WIDOWS OF EX-SERVICEMEN Name of applicant ___________________________________________ Photo Date of birth/Age ___________________________________________ Address ___________________________________________________ Tehsil or Police Station ______________________ Tel_________________________________ Service particulars of husband: Name : ____________________________________No. __________________________ Rank_____________________________ Date of Birth __________________________ Date of Enrolment _________________ Date of Death Date of Discharge __________________ Discharge Book No PPO No. _______________________________________________________________ Decoration__________________________ Regt/Corps __________________________ Death Details of husband : War/Operation in which died _______________________________________________ Attributable _____________________________________________________________ Non-Attributable _________________________________________________________ After Retirement _________________________________________________________ Details of family ( only dependent children upto 25 years and dependent parents of deceased Ex-servicemen ) Name Age Relationship Educational Qualification i) ii) iii) iv) Amount of family pension OrdinaryRs _________________Special Rs ______________ Liberalised special family pension Rs. _______________________ Lump sum Payment Received : (By her & husband) Gratuity Rs. __________________________Group insurance Rs.______________________ Encashment of Leave Rs. ______________ Financial Assistance Rs.___________________ Commuted Pension Rs. ________________ Present occupation and monthly Income Service Rs. __________________________ Business/Industry Rs.___________________ Agriculture Rs. _______________________ Unemployed__________________________ Other relevant Information, if any Identification Mark: Left Hand Thumb Impression:____________________________________________________ - 2 - DECLARATION I hereby declare that the particulars given above are true to the best of my knowledge and belief Date: ____________________ Place: ____________________ (Signature of Applicant) FOR OFFICE USE Status as widow Yes/No Category: War widow___________________ Attributable___________________ Non Attributable_______________ After Retirement_______________ Identity Card Issued to Late Ex-servicemen _________________________ No. & Date of identity Card Issued_________________________________ Date: ______________________ Place: ______________________ (Signature of Secretary RSB/ZSB with Office stamp & date)
