APPLICATION FORM FOR FINANCIAL ASSISTANCE FROM THE TAMIL NADU EX-SERVICES PERSONNEL BENEVOLENT FUND FUNERAL GRANT Identity Card No. : NR No. : 1. Name of the applicant : 2. Full postal address : 3. Full permanent address : 4. Relationship of applicant : to the deceased ex-Servicemen 5. (i) Age of applicant on the : Date of application 6. DETAILS OF SERVICE OF DECEASED EX-SERVICEMEN Regimental No. Rank Name Unit Date of Enrolment Date of Discharge Cause of Discharge Character State from which enrolled 7. Details of death of Ex-Serviceman (i) Date of Death (ii) Place of Death (iii) Cause of Death 8. If applying after last rites (i) Nature of last rite -FUNERAL/BURIAL (ii) Place where conducted (iii) Date when conducted 9. Family details Sl.No. Name Age Relation Details Monthly -ship of what Income they do I request that I may kindly be sanctioned the funeral grant from Tamil Nadu Ex-Services Personnel Benevolent Fund to the extent eligible. I certify that the above details are correct and true to the best of my knowledge. I enclose the relevant documents connected with my application. Enclosures 1. Photo copy of the Discharge Certificate OR Particulars of Service duly attested. 2. Original identity card of Ex-Servicemen. 3. Death Certificate or Certificate from Panchayat member/ward councillor of the area where the of Ex-Servicemen lived. 4. Copy of ration card Signature of the applicant or Left Thumb Impression Place : Date : If Left Thumb Impression, details of witnesses. Sl.No. Name and Address Signature 1. 2. CERTIFICATE FROM PANCHAYAT MEMBER, MUNICIPAL COUNCILLOR OF THE LOCATION WHERE EX-SERVICEMEN WAS LIVING I Certify that the following details are true :- Regimental Number of deceased ex-Servicemen : Rank : Name : Date of Death : Place of Death : The applicant Tmt/Selvan/Selvi................... is the Wife/Son/Daughter of the deceased ex-servicemen. The last rites were conducted as under:-Date : Place : Signature Name: Office Seal Occupation: Place: Date:
