(See paras 28 and 34) APPLICATION FOR FINANCIAL ASSISTANCE FROM WELFARE FUND IN CASE OF DEATH OF AN OFFICIAL / GD SEVAK / CASUAL LABOURER / DAILY RATED STAFF WHILE IN SERVICE _____________________________________________________________________________ _ (Portion to be filled up by the Applicant) 1.
Name of the Official
:
2.
Designation
:
3.
Office where the official was working
:
4.
Date of Death
:
5.
Basic Pay
:
6.
Name of the Dependent applying for financial assistance.
:
7.
Relationship of the applicant to the official :
8.
Full address of the applicant
:
9. Length of Service : 10. Particulars of the family members of the official : Name Relationship of the Whether employed, if Remark applicant with the so Salary & Designation official
11.
Financial conditions of the family
:
Place : Date : Signature of the Applicant _____________________________________________________________________________ _ (Portion to be filled up by the Unit Officer) 1. 2. 3. 4.
Whether the above information has been verified Whether the official died while in service Date of continuous service of the official and the length of service on the date of death. Recommendations.
Place : Date :
: : : : Signature of the Unit Officer
_____________________________________________________________________________ _