APPLICATION FORM FOR REIMBURSEMENT OF HOUSE TAX PAID FROM THE TAMIL NADU EX-SERVICES PERSONNEL BENEVOLENT FUND Identity Card No. NR. No. DETAILS OF THE EX-SERVICEMAN : 1. Regimental Number : 2. Rank : 3. Name : 4. Corps/ Regiment/ Branch : 5. Date of Enrolment : 6. Date of discharge : 7. Cause of discharge : 8. Character : 9. Date of Death : 10. Place of Death : II DETAILS OF THE WIDOW : 11. Name : 12. Address : 13. Date of marriage with the ex-Serviceman/Serviceman : 14. Age / Date of Birth : 15. (i) Details of the income : (a) Amount (b) Pension payment Order No. (c) Pension drawn from where (d) Bank Account No. / Treasury No. (ii) Present employment : (a) Employer (b) Monthly Income : (iii) Type of business (a) Annual Income (iv) Total Annual Income (v) Income Tax PNR No. (vi) Tax paid during the last year III DETAILS OF THE HOUSE : 16. The House is in whose name ? : 17. (a) Whether the demand and : receipt for the house tax are in the name of the applicant (b) Receipt No. date of payment :---------------------------------------------------- and the amount Receipt Date Amount No. Rs. 18. The particulars of the house : owned by the applicant Sl. Door No., Street, Place, Value of Annual House No. Name of the Panchayat the house Tax and Taluk 19. Whether the entire house or : portions of the house are let out, If so, the name of the tenant and of rental income IV DETAILS OF INCOME : 20. The total annual income of : the applicant 21. Whether the applicant is paying income tax? I assure that the details furnished above are true and in case of any false information. I hereby agree to repay the reimbursement of House Tax paid to me. I have enclose the following documents : 1. Certificate from the Revenue Department. (a) Regarding the applicant owning only one house and that he/she is resident therein. (b) No rental is derived from the house. 2. The receipt for the payment of house tax. 3. The Death certificate of the ex-Serviceman, where applicable 4. Non assessee to Income Tax Certificate 5. Xerox copy of the Discharge Certificate OR particulars of Service duly attested. 6. Xerox copy of ex-Serviceman/widow Identity Card 7. Income Certificate issued by Revenue Department ( an officer in rank not less than Deputy Tahsildar), where applicable. Signature of the applicant OR Left Thumb Impression Place : Date : If Left Thumb Impression, details of witnesses Sl.No. Name and Address Signature 1. 2. LIST OF DOCUMENTS TO BE ATTACHED WITH THE APPLICATION 1. Certificate from the Revenue Department a) Regarding the applicant owning only one house and that he/she is resident therein b) No rental is derived from the house 2. The receipt for the payment of house tax 3. The Death certificate of the Ex-Serviceman, where applicable 4. Certificate by applicant that she/he is not an Income Tax Payee 5. Xerox copy of the Discharge Certificate OR Record of Service (officers) duly attested 6. Income Certificate issued by Revenue Department ( an officer in rank not less than Deputy Tahsildar ) where applicable
