298 [SCH.

XV

FORM 17

(Referred to in rule 25 Schedule XV)

Form of application for the grant of family pension on the death of a

Government servant while in service/after his retirement.

1. Name of the applicant.

2. (i) Name of the guardian in case the applicant is minor.

(ii) Relationship of the guardian with the applicant.

3. Name of the deceased Government servant/pensioner.

4. Relationship of the applicant with the deceased Government servant/pensioner.

5. Date of death of the Government servant/pensioner.

6. Office/Department in which the deceased served last.

7. (i) Date of birth of the applicant.

(ii) Date of birth of the guardian in case the applicant is a minor.

8. Full address of the applicant/guardian.

9. Name of the Treasury or Sub-Treasury at which payment is desired.

10. Enclosures.

(i) Two specimen signatures of the applicant duly attested (to be

furnished on two separate sheets).

(ii) Two copies of a passport size photograph of the applicant duly

attested.

(iii) *Two slips each bearing left hand thumb and finger impressions of
the applicant duly attested.

(iv) Description Roll of the applicant duly attested indicating (a) height and
(b) personal marks. if any on the hand, face etc.
(To be furnished in duplicate).

(v) If the applicant belongs to a category mentioned at (b) of item 11 below he/she
should produce reasonable proof of his/her dependence on the deceased Government
servant/pensioner for support.
________________________________________________________________________________________
*To be furnished in case the applicant is not literate to sign his name.
SCH. XV] 299

(vi) If the applicant is a minor brother of the deceased Government servant/pensioner, certificate of age (in original with two attested copies)
showing the date of birth should be furnished. (The original will be returned to the applicant after necessary verification).

vii) Affidavit (please see paragraph 2 of Form 16).

II. Name and age of surviving kindred of the deceased Government

servant/pensioner.

Name Date of birth by Christian era.

(a) Widow/Husband, Sons,

Unmarried daughters. widowed daughters.

(b) Father,
Mother,
Brother below the age of eighteen years,
Unmarried sisters,
Widowed sisters.

12. Signature or thumb impression of the applicant.

13. Attested by:

Name Full address Signature

(i)

(ii)

14. Witness:
Name Full address Signature

(i)

(ii)

Note 1. Attestation should be done by two Gazetted Government servants or by two or more persons of respectability in the town/village or panchayat
in which the applicant resides.

Note 2.-lf the applicant is a minor the enclosures against item 10 (i) to (iv) are to be furnished by the guardian.