Department of Information and Pubilicity FORM-I (See Clause 6) Application for grant of Ex-Gratia to the Family of Deceased /Incapacitated Press Personnels 1 Name of the Applicant : 2 Relationship to the Deceased Press Persons : 3 Father's/Husband's name of the applicant : 4 Name of the Deceased Press Personnel : 5 Name of other dependent family members : 6 Name Occupation Relationship Age 7 Date of Death : 8 Nature of Death : Natural/Accident/Chronic Disease (Please furnish certificate from Municipality or Commune Panchayat/Police/Doctor) 9 In case of permanent disability, nature and extent of disability (Please enclose disability Certificate) : 10 Name of the Media in which the deceased Preson Person has worked : 11 Periodicity : 12 Nature of duty (Please enclose service certifiate issued by the Employer) : 13 Length of service of the deceased Press persons in the filed (Certificate issued by the Newspaper/Journal/Agency or other Media Authority to be attached in original) : 14 15 Whether he is a full time employee Whether the deceased Press Person has been a member of any other Journalist Association of Puducherry Union Territory. : : Yes / No (If yes, please furnish a recommendation from any Journalist Association of Puducherry Union Territory) 16 Whether the deceased Press Persons Accredited Press Persons (If Yes, please furnish details ) : 17 Nationality of the Applicant : 18 Whether the applicant is a native of U.T. of Puducherry either or by continuous residence (Nativity / Residence Certificate to be attached) : 29 19 Address : Present : Permanent : 20 Whether the applicant is a legal heir of the : deceased Press Person (Please furnish the Legal Heir Certificate from the competent authority) : : DECLARATION I ..................... hereby solemnly affirm and declare that the particulars furnished above are true and I have not suppressed any material fact that will disentitle me for the grant of Ex-gratia under "PRESS PERSONNEL FAMILY WELFARE SCHEME-2005" Signature of the Applicant Place : Date : 30 FORM - II (See Clause 6 (d) SERVICE CERTIFICATE Certified that Thiru/Tmt ........................S/o, W/o ........................ had worked continuously for the period of ...........years from ........... to......... as Full time Editor/Sub-Editor/Reporter/Correspondent of the Print/Electronic Media viz.......................... registered with the Registrar of Newspapers of India/Ministry of Information and Broadcasting, Government of India, New Delhi vide No................... Place: Signature : Date : Name : Designation: 31 FORM - III See Clause 7 (1) VERIFICATION CERTIFICATE (To be Verified and Certified by the Assistant Director, Directorate of Information and Publicity) Certified that the application of Thiru/Tmt.................... S/o, W/o. ................................. for providing one time ex-gratia to the family of deceased / incapacitated Press person of Puducherry Union Territory has been scrutinized under the "Grant of Press Personnel Family Welfare Scheme-2005" and the particulars furnished by him/her therein are found to be correct. Place: Signature : Date : Name : Designation:
