FORM -III PART -I APPLICATION FOR GRANT OF FINANCIAL ASSISTANCE FROM SSB STAFF BENEVOLENT FUND 01 Personnel No. Rank & Name of the Subscriber 02 Name of Office of subscriber 03 SSB Staff Benevolent Fund membership number allotted and date of commencement of membership 04 Date of joining Govt. Service 05 Particulars of subscription last realized and remitted 06 Name of the applicant and relationship with subscriber 07 Basic Pay at the time of death/submission of application (indicate date) 08 Whether application is a) for financial assistance on death of the subscriber b) for financial assistance other cases under Rule-2(b) 09 Financial assistance in case of death a) Place of death b) Date of causality c) Cause of death d) Amount of financial assistance 10 For financial assistance in other cases (other than death) a) Purpose of which financial assistance is sought b) Further expenditure to be incurred (give details separately with documentary proof) c) If under treatment, duration of treatment also indicating where treatment undertaken/being undertaken (with documentary proof) d) Amount reimbursed or compensation received against the total expenditure incurred (full details of amount received from different sources to be supported by some documentary proof) : 2 : e) Details of leave availed on account of sickness etc (give documentary proof) i) Earned Leave ii) Commuted leave - iii) Half Pay leave - iv) EOL/Leave without Pay - v) Any other kind of leave availed (to be verified by the Head of Office) - 11) Any other member of family i.e. wife unmarried son or unmarried daughter in service and their income NA 12) No and name of dependent family members Name Age Relationship 13) Permanent Address 14) Present Address Certified that the information given above is complete and correct to the best of my knowledge. Signature of Applicant PART - II RECOMMENDATION OF REGIONAL COMMITTEE AS REQUIRED UNDER RULE -2 OF THE SSB STAFF BENEVOLENT FUND No. _____________ rank ______________ Name_______________________ was posted to _______________ and expired on ____________ due to ___________________ (copy of death certificate issued by the Gram Panchayat Behal is enclosed herewith. No.______________ Rank___________ Name_________________________ had been subscribing towards SSB Staff Benevolent Fund and the subscription for the year/ month _______________ (up to) has been remitted to the Treasurer, SSB Staff Benevolent Fund, New Delhi vide DD No. ___________________dated ___________ for Rs. _____________ (Rupees ____________________________________________________________) only. The Committee therefore recommends the Smt ____________________ (Name of next of kin) may be sanctioned a sum of Rs. 6,50,000/- (Rupees six lakhs fifty thousand) only from SSB Staff Benevolent Fund as financial assistance. Member-I Member-III Member-III Member-IV Member-V Member-VI Chairman Countersigned by
