SWATANTRA SAINIK SAMMAN PENSION SCHEME Application form (TO BE SENT BY REGISERED POST IN DUPLICATE - ONE COPY TO BE SENT TO THE STATE GOVERNMENT CONCERNED AND ONE COPY TO THE DEPUTY SECRETARY TO THE GOVERENMENT OF INDIA, MINISTRY OF HOME AFFAIRS, FREEDOM FIGHTERS DIVISION, FIRST FLOOR, LOK NAYAK BHAVAN, NEW DELHI.) In case you had previously applied to the Central Govt. SPACE FOR PASSPORT for Freedom Fighters pension please quote Ministry of SIZE PHOTOGRAPH OF home Affair's Reference No. & Date. FREEDOM FIGHTER/WIDOW ..................... ..................... ..................... Part - I: Personal Particulars 1. Name of the Applicant : (In block letters) 2. Address : 3. Age of the applicant : 4. Name of the Freedom Fighter : (If the applicant is a dependent) 5. Address of the Freedom Fighter : 6. Relationship of the applicant to : the Freedom Fighter 7. Nationality : 8. Occupation : 9. Names of dependent family Name Age Relationship members, their age and relationship to the applicant family includes mother, father, widower, widow (If she has not remarried and unmarried daughters) 10. Whether he or she is receiving : pension from the State Government, under the State Scheme, if so, amount Part - II Particulars of suffering undergone during the Freedom Struggle 11. (i) Imprisonment: (a) Details of the case in which tried and : awarded imprisonment (b) Name & Place of the Court which tried the : case and awarded punishment (c) Sentence awarded : (d) Actual Period of imprisonment suffered : From To (e) Evidence (i) Court Judgement : (ii) Jail Certificate : (iii) Co-prisoner Certificate : (This should be in the prescribed form attached at Annexure -I) (ii) Underground : (iii) Externment : (iv) Internment : (a) Type of evidence produced partial or full e.g. court's records, warrant of arrest declaration as absconder etc. (b) Internment Orders; Date of Orders, Date of lifting (c) Externment Orders, Date of Orders, Date of lifting. * If no evidence, partial or full is : available from official records whether suffering at (ii), (iii) or (iv) should be supported by certificates from prominent freedom fighters. If so, furnish name of the certifier, the State to which he belongs, particulars of jail sufferings undergone by him. (V) Loss of Job/means of Livelihood : Type of evidence produced. (i) Official records in support of dismissal. (ii) Whether re-employed after Independence : If so, details of post-independence service : Note: Jobs would refer to jobs in Government or in Local Bodies such as District Boards and Municipalities. (VI) Loss of property - confiscation: (i) details to be supported by evidence from official records. (ii) Whether any compensation was paid by the State Govt. after Independence : (VII) Permanent incapacitation: Type of evidence to be produced; (a) Certificate from the District Magistrate that permanent incapacitation was done due to bullet injury/lathi charge sustained during participation in the Freedom Struggle. (b) Medical Certificate from the Civil surgeon in support of the handicap. (VIII) Martyrdom : (i) Evidence from records in support of having been killed during police firing or in the case of INA killed in action in the war front. 12. In case of ex-INA personnel only. (i) Whether military or civilian category. If military type of evidence required. (a) Discharge certificate : (b) Whether classified as Black or Grey : (c) Record office letter showing forfeited pay and allowances. : (ii) If civilians: (a) One co-prisoner certificate in the affidavit form from a freedom fighter pensioner. (b) Movement order. 13. Any other relevant information which the applicant would like to furnish. : 14. If the applicant is a member of Scheduled Caste/Scheduled Tribe (A certificate from the District Magistrate should be attached) Place: Signature of the applicant Date: AFFIDAVIT I, ......... S/o. Shri ................ aged ........ occupation .............resident of ............. do hereby state on solemn affirmation that what is stated in columns 1 to 14 of the application form is on the basis of my personal knowledge and belief and no false information or document has been furnished by me to get the pension or benefits from the government. Deponent: Solemnly affirmed at............ this day of ............... And his name in my presence, before me. Judicial magistrate, First Class. N.B. 1. The Particulars in the application should be supported by a sworn affidavit. 2. Copies of certificates produced should be attested by a competent authority. Originals of these documents should be produced as and when demanded. 3. Only applications which are complete in all respects and are companied by affidavit, Jail and other prescribed certificates will be entertained. 4. The last date for receipt of application will be 31-7-1981. 5. An attested passport size photograph of the applicant should be affixed in the space provided. ANNEXURE II Form of application To The District Collector .............. Through the Tahsildar of ................. 1. Name in full (In capital letters) : 2. Full address : 3. Particulars regarding the Freedom movement in which the Freedom Fighter participated together with dates during which and the Jail in which : imprisonment was undergone 4. Total income of the Freedom Fighter/claimant : including help from near relatives. 5. Whether any other assistance has been received by the Freedom Fighter/claimant either from the Government of India or from the State : Government. 6. Identification marks: 1. 2. 7. I hereby certify that (a) my income from all sources including help from near relatives in Rs......per month. (b) All the above particulars furnished by me are true and correct to the best of my knowledge. Place: Date: Signature of the Applicant Copy to the District Collector ................(direct) (PERSONAL KNOWLEDGE CERTIFICATE) ANNEXURE II I, (the undersigned) .............. son of / daughter/wife of Shri ..............andresidentof(Fulladdress) ........................... have taken prominent part in the National Freedom Struggle and have been recipient of Central Freedom Fighter's Pension under Ministry of Home Affairs Order No..........dated............ I suffered actual imprisonment for more than 2 years during the freedom struggle and was lodged in .............. jail, in...........District during the period from ............ to ........... I hereby certify that Shri/Smt......................son /daughter/wife of Shri ........ resident of .......District is a bonafide freedom fighter who (a) Remained underground freedom for more than six months for the period from ................to..................as he/she was (i) A proclaimed offender; or (ii) One on whom an award for arrest was announced; (iii) One for whose detention orders were issued but he evaded arrest. (b) Ordered to be externed from his district, or interned in his home a period of more than six months from.............to............by the ............ Court ..............in case No. ................of 19..... on account of his/her participation in the................movement during the freedom struggle. To the best of my knowledge and belief he/she did not secure reprieve on account of any oral or written apology tendered by him/her. He/she also did not go underground voluntarily or for fear of arrest on account of his/her patriotic activities. I hereby give an unconditional undertaking that if any information given above is subsequently found to be wrong or false, the Central Government will be authorized to cancel my pension and I will be liable to refund the entire amount of pension already drawn. Signature Name of the certifier (In block letters) ............. Dated at (Place)...............on the........... Day of ............ 19.... (CO-PRISONER CERTIFICATE) I (the undersigned) .................... son / daughter / wife of shri ............. am a freedom fighter and have been recipient of Central Freedom Fightser's Pension under Ministry of Home affairs, order No........dated............in the State/Union Territory is an eligible certifier under the Liberalised 1980 Swatantrata Sainik Samman Pension Scheme. 2. I was involved in Case No............u/s........ .......which was tried by Shri...................(Name of the Magistrate and Place) and was sentenced to imprisonment for a period of........years/months in the Year........... 3. I suffered imprisonment during the freedom struggle and was lodged in........ ..... Jail in..................District during the period from ........to......... 4. I hereby certify that Shri/Smt/Kumari............ son/daughter/wife of Shri ................ resident of............... ......district is a bonafide freedom fighter who was also imprisoned on account of his/her participation in the ..........Movement during the freedom struggle, was tried by the Court of..........in the year........ and was lodged in the same jail along with me during the period from.......to......... 5. To the best of my knowledge and belief he/she was not prematurely released from jail on account of any oral or written apology tendered by him/her. 6. If any information given above is subsequently found to be false or wrong I hereby give an undertaking that my pension can be cancelled forthwith and I will be liable to pay the amount of pension drawn till date. Signature........ Name of the Certifier (In block letters) ............. Dated at (Place)................on the..........day of ........
