SWATANTRATA SAINIK SAMMAN PENSION SCHEME APPLICATION FORM PART- I PERSONAL PARTICULARS 1. Name of Applicant: ____________________________ (In Block Letters) 2. Address: ___________________________ 3. Age of Applicant : ______________________________ (if the applicant is dependent) 4.Name of Freedom Fighter (if the applicant is dependent) ______________________________ 5.Realtionship of the applicant to ______________________________ the Freedom fighters 6.Address of Freedom Fighter ______________________________ 7. Nationality: _____________________________ 8. Occupation: _____________________________ 9. Name of the dependent family _____________________________ members, their age and relationship to the applicant family includes _____________________________ mother, father widower, widow (if she is not remarried) and unmarried _____________________________ daughters. 10. Whether he or she is receiving pension from the State Government ____________________________ under the State Scheme, if so amount Place : Signature of Applicant. Date: PART II PARTICULARS OF SUFFERING UNDERGONE DURING THE FREEDOM STRUGGLE. 11. i) IMPRISONMENT a) Details of the case in which tries and awarded the imprisonment ___________________________ b) Name and place for the court which tried the case and awarded ___________________________ punishment. c) Sentenced Awarded ________________________ d) Actual Period of imprisonment suffered From To Evidence: i) Court Judgement __________________________ ii) Jail Certificate __________________________ iii) Co-Prisoners Certificate ___________________________ ii) Underground ___________________________ iii) Exterment ___________________________ iv) Interment ___________________________ a) Type of evidence produced partial or full e.g. courts records, warrants of arrest declaration as absconder etc. b) Interment Orders ___________________________ Date of Orders ___________________________ Date of lifting ___________________________ If no evidence ,partial or full is available from official record whether suffering at (ii) or (iv) is supported by certificates from permanent freedom fighters, if so, name of the certificates state of which he belongs particulars of jail suffering under by him. v) loss of job/mean of livelihood type of evidence produced. i) Officials records in support of dismissal ii) Whether Re-employed after independence, details of Post Independence Service. Note: Jobs could refer to jobs in Govt. or in Local Bodies such as District Boards and Municipalities. vi) Loss or Property Confiscation i) details to be supported by evidence from official records ii)whether any compensation was paid by the State Government after Independence. vii) Permanent incapacitation Type of Evidence to be produced. (a) Certificate from the District Magistrate that permanent incapacitation was done to bullet injury/ lathi charge sustained during participation in the Freedom Struggle. (b) Medical certificate from the Civil surgeon in support of Handicap. viii) Martyrdom: Evidence from records I support of having been killed during police firing or in case of INA fin action killed/ War Front. 12) In case of EX- INA/ Personal only; whether Military or Civilian category if military type Evidence required. i) Discharge Certificate ii) Whether classified as Black or Grey. iii) Record office better/ showing Forfeited pay and allowance If Civilian: a) On Co-Prisoner certificate in the /form affidavit/ from a Freedom Fighter Prisoner. b) Movement order 13) Any other relevant information which the applicant would like to furnish. 14) If the applicant is member of the Schedule Caste/ Schedule Tribe ( A certificate from the District Magistrate should be attached.) Place : Signature of Applicant. Date:
