Eastern Railway

Performa for Family Declaration for Passes, PTOs for the year ………...
Present posting ……………

01. Name of Declaring: 04. Date of Apt.: 07. PF A/c No.:

02. Designation : 05. Rate of Pay: 08. Residential Address:
03. Office Address: 06. Date of Birth

Family Members: - i) Father is alive? Yes/No ii) Mother’s monthly income is Rs……………

Whether
Occupation & Whether
Sl. Father’s/Husband’s Date of Relation with married/
N a m e source of wholly
No. Name Birth the Employee unmarried/
Income, if any dependent
Widow
01.

02.

03.

04.

05.

Declaration: I do hereby declare that the above family members/dependent relatives included in this declaration actually member of my household
entirely dependent on me for their means of subsistence & residing with me.

Station:

Date:
Signature / LTI of the employee.
Signature of Supervisor