FORM - 12 Application for The Grant of Death-cum-Retirement Gratuity on the Death of a Government Servant. (See Rules 77 (3) and 79 (2) ) (To be filled in separately by each claimant and in case the claimant is minor, the Form should be filled in by the guardian on his/her behalf, where there are more than one minor, the guardian should claim gratuity in one Form on their behalf.) 1. (i) Name of the claimant in case he is not minor: (ii) Date of birth of the claimant: 2. (i) Name of the guardian in case the claimants are minors: (ii) Date of birth of the guardian: 3. (i) (ii) Name of the deceased Government Date of death of Government Servant: (iii) Office/Department/Ministry in 4. Relationship of the claimant/ 5. Full Postal Address of the claimant/guardian: 6. (i) Where gratuity is claimed by the guardian on behalf of minors, the names of the minor their ages relationship with the deceased Government servant, etc.- servant in respectof whom gratuity is being claimed: which the deceased served last. guardian with the deceased Government Servant. GOVERNMENT OF JHARKHAND Published on National Portal of India (india.gov.in) Department of Finance 7. Name of the Treasury of Sub-Treasury at which payment is desired. Signature/Thumb impression of the claimant/ guardian. 8. Two specimen signature, or left hand thumb and finger impression of the claimant/guardian duly attested. (to be furnished in separate sheet) 9. Attested by :- Name Full Address Signature (i) (ii) 10. Witnesses:- Name Full Address Signature (i) (ii) Published on National Portal of India (india.gov.in) (ii) Relationship of the guardian with minors :- Sl.No. Name Age Postal AddressRelation with the deceased Government servant. 1. 2. 3.
