Application for extraordinary family pension in respect of late Shri/Smt.
......................................................................................... killed or died of injury(ies)/disease(s) claimed as attributable to Government Service.
I. Information regarding the deceased
1. Full name and address
2. Name of Father OR Mother
Or Both 3. Date of death
II. Information regarding the claimant
4. Name and address, (showing
Village, Post Office, District, State, PIN code)
5. Date of birth
6 Aadhar Number ( if any)
7. Monthly income from all sources 8. Relationship with the deceased
9. Bank name Branch address Account No. BSR Code/IFSC Code
III. Details of surviving members of family of the deceased
Relation Name Date of birth Disability, if Marital
(Christian Era) any status Widow/Widower
Sons
Daughters
Father
Mother
Brother Sister
IV. In case the claimant is minor or suffering from disorder or disability of mind, including mental retardation, details of guardian/nominee, wherever applicable-
Name Date of Relationship with Relationship with Postal address
birth the minor/ the deceased mentally disabled Government claimant servant
Enclosures: 1. Report of medical examination of the deceased employee
(Copies of) 2. Guardianship certificate, if applicable 3. Disability certificate of the claimant, if any 4. Income certificate
Specimen signature/thumb impression and two photographs of the applicant, attested by a Gazetted Officer are enclosed.
Place: Date: (Signature of claimant) Phone No: Permanent Account Number for Income Tax (PAN)…………………….. Aadhar No., if available - ………………………………
NOTE: If the deceased has left no son, widow, daughter, father or mother, brother or sister surviving him, the word “None” should be entered opposite to such relative.
