FORM - 14 (See rule 77(4), 79(3) and 61(2) Application Form for Family Pension on the Death of a Government Servant/Pensioner 1. Name of the applicant: (i) 2. Sl.No. Name 3. Date of death of the: Government servant Pensioner. 4. Office/Department/Ministry: In which the deceased Government servant Pensioner served last. 5. If the applicant is guardian: His date of birth and relationship with the deceased Government Servant/Pensioner 6. Full address of the applicant: Widow Widower (ii) Guardian if the deseased Pension is survived by Child or children Relationship With the decesed Govt. Date of birth by children age Christian era. JHARKHAND GOVERNMENT Published on National Portal of India (india.gov.in) Yes No Name and age of severing : Widow Widower Children Of the deceased Government Servant/Pensioner iii. ii. i. iv. 9. Signature or left hand thumb impression of the applicant. 8. Enclosures: (i)Two specimen signature of the applicant duly attested (To befurnished in two separate sheets) (ii)Two copies of passport size Photograph of the applicant, duly attested. Submitted Not Submitted (iii) Two splis each bearing left Hand thumb and finger Impression of the applicant, (iv) Descriptive Roll of the applicant duly attested, indicating (a) heightand (b) personal marks, if any,on the hand, face etc. (v) Certificate(s) of age (in original with two attested copies) showing the date of birth of the children.The certificate should be from theMunicipal Authorities or from the local Panchayat or from the local Panchayat or from the head of a studying 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.) 10.Attested by: Name Full Address Signature 11. Witness: 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. *To be furnished in case the applicant is not literate enough to sign. his name. Published on National Portal of India (india.gov.in) Submitted Not Submitted Not SubmittedSubmitted Not SubmittedSubmitted Not Submitted Submitted 7. Name of the Treasury or Sub- Treasury at which payment is Desired.
