From Smt __________________ W/o Late________________ C/O __________________ Street __________________ Village__________________ Post __________________ Dist __________________ State __________________ Pin __________________ To, The Director General (for DD(OA&R) Coast Guard Headquarters National Stadium Complex New Delhi-110 001 (in case of widow of officers) Or The Officer-in-Charge Bureau of Naviks Cheetah Camp, Mankhurd Mumbai- 400 088 (in case of widow of Enrolled Personnel) SUBJECT - ISSUE OF DEPENDENT IDENTITY CARD TO SMT_______________WIDOW OF LATE (NAME______________RANK_________ NO_______) 1. I, Smt_________________ wife of late (Name ____________________Rank_________ No ___________) and drawing family pension vide P.P.O No. ____________dated ________ hereby apply for the issue of dependent identity card for myself. Proforma (Part I to IV) duly completed is enclosed herewith. 2. It is requested that the dependent identity card may be issued to me and forwarded on the above mentioned address. Thanking you, Yours faithfully, (Signature of applicant) Name: ________________ Widow of: Name --------------------------- Rank----------------------------- No-------------------------------- Date_________________ PART - I PARTICULARS OF DECEASED (OFFICER/ENROLLED PERSONNEL) Rank _______________ Name _____________________________ No _____________ Last Unit/Ship ___________________________________________________________ Date of Casualty _______________________ War/Operation _____________________ Date retired from service (Only Pensioner) _____________________________________ ________________________________________________________________________ PART - II PARTICULARS OF WIDOW (PENSIONER) Name ____________________________________________________ Date of Birth ______________________________________________ Identification Mark _________________________________________ Permanent Home Address ___________________________________ _________________________________________________________ _________________________________________________________ P.P.O No ____________________Signature_____________________ Left Thumb Impression ________________________________________________________________________ PART - III I here by certify that the particulars given above are true to the best of my knowledge and I have not remarried. Place : ___________________ ________________________ Date : ___________________ (Signature of Widow) ________________________________________________________________________ PART - IV COUNTERSIGNED Zila Sainik Board/ OC NCC Unit/Serving Gazetted Officer ________________________________________________________________________ PART - V It is certified that the particulars mentioned above are correct as per the record held DD (OA&R) Officer-in-Charge Indian Coast Guard Headquarters Bureau of Naviks National Stadium Complex Cheetah Camp, Mankhurd New Delhi - 110 001 Mumbai - 400 088 Date _______________ Date __________________ Passport Size photograph of Widow
