REGISTRATION FORM - WIDOWS / WAR WIDOWS OF EXSERVICEMEN 1. Name Stamp Size Photograph 2. Date of Birth / Age 3. Address Tehsil or Police Station Tele 4. Particulars of husband: No. Date of Enrolment Rank Date of discharge Name Discharge Book No. & Date Decoration Regt / Corps PPO No. & Date Religion: Caste: DECLARATION 5. Details of husband's Death: War / Operation Attributable Non Attributable After Retirement 6. Details of family (only dependent children upto 25 years and dependent parents of deceased Ex-Servicemen) Name Age Relationship Educational Qualification (i) (ii) (iii) (iv) (v) (vi) (vii) 7. Amount of Family Pension: Ordinary Family Pension Rs. Special Family Pension Rs. Liberalised Special Family Pension Rs. 8. Lump sum payment Received by her & husband: Gratuity Rs. Group Insurance Rs. Leave encashment Rs. Financial Assistance Rs. Commuted Pension Rs. 9. Present occupation & monthly income Service Rs. Business / Industry Rs. Agriculture Rs. un-employed 10. Other relevant information, if any. 11. Identification Marks: 12. Left Thumb Impression: I hereby declare that the above information is true to the best of my knowledge and belief. Date: Signature of Applicant. Place: FOR OFFICE USE Status as Widow : Yes / No. Category War Widow Attributable Non Attributable After Retirement No. & Date of Identity Card issued. Date : Signature Secretary, Place: DSS&A Board with Office Stamp & Date.
