Revised Form No. 10 (Pension) FORM OF APPLICATION FOR FAMILY PENSION (Under the Family Pension Scheme, 1969) 1. Name of the applicant (i) Widow/Widower (ii) Guardian if the deceased person Is survived by child or children 2. Name and age of surviving widow/widower and children of the deceased Government servant 3. Date of death of the Government servant 4. Office/Deptt. in which the deceased Government servant/pensioner served last 5. If the applicant is guardian, his date of birth and Sl.no Name Relationship with Deceased person Date of birth by Christian era relationship with the deceased Government/pensioner 5. A. If the applicant is a widow/widower the amount of service pension which she/he may be in receipt on the date of death of the husband/wife 6. Full address of the applicant 7. Name of the Treasury or Sub-Treasury at which payment Is desired 8. Enclosures (i) Two specimen signature of the applicant, duly attested (to be furnished in two separate sheets) (ii) Three copies of passport size photograph of the applicant duly attested (iii) Two slips each bearing left hand thumb and finger impression of the applicant, duly attested (iv) Descriptive Roll of the applicant duly attested, indicating (a) height and (b) personal marks, if any, on the hand, face, etc (to be furnished in duplicate) (v) Cetificate (s) of age (in original with two attested copies) showing the date of birth of the children. The certificate should be from the Municipal Authority or from the Local Panchayat or from the Head of a recognized school if the child is studing in such school. (This information should be furnished in respect of such child or children the particulars of whose date of birth are not available with the Audit Officer/Head of Office) 9. Signature or left-hand thumb impression to be furnished in case the Applicant is not literate enough to sign his name 10. Attested by: 11. Witness: Sl. No. Name Full Address Signature (i) (ii) Sl. No. Name Full Address Signature (i) (ii) NOTE: Attestation should be done by two Gazetted Government servants or two or more persons of responsibility in the town, village or Pargana in which the applicant resides.
