I, Sri/Smt. working as at School, Village/Town of Mandal, hereby declare that I was married to Sri/Smt. S/o / D/o on at .
I further declare that the above information is true and correct to the best of my knowledge and belief. I request that my marriage particulars may kindly be entered in my Service Register (SR).
I, , working as at School, Village/Town of Mandal hereby declare that my home town is at the place as shown below for the purpose of availing Leave Travel Concession for self and family as noted in the Govt. of India, Ministry of Home Affairs, New Delhi vide O.M. No. 43/1/55/Estts-(A) Part-II dated 11.01.1956. And I hereby request my HOO to enter these details in my Service Register.
| Home Town / Village | Mandal | Division | District & State | Nearest Railway Station | Nearest Airport | Instance / Distance |
|---|---|---|---|---|---|---|
I, Smt./Sri Working as at School, Village/Town of Mandal hereby declare that I have married on: to and I am having the following legitimate family members/dependents who actually live with me and depend upon my earning.
| Sl. No. |
Name of the Family Member | Gender | Relationship | D.O.B | Blood Group |
Employment Status |
ID / Ref No. | Marital Status |
|---|---|---|---|---|---|---|---|---|
| 1 | Married | |||||||
| 2 | ||||||||
| 3 | ||||||||
| 4 | ||||||||
| 5 | ||||||||
| 6 | ||||||||
| 7 |
I, Smt./Sri Working as at School, Village/Town of Mandal hereby declare that I have married on: to and I am having the following legitimate family members/dependents who actually live with me and depend upon my earning. I nominate the following family member(s) of my family to receive the Death-cum-Retirement Gratuity, G.I.S Final claims, APGLI final claims, GPF/ZPGPF Final claims and other pensionary benefits from the Govt. in case of death while in service. I hereby request my HOO to record these details in my Service Register. In support of my nomination I have taken witness of two Govt. employees/others as shown below.
| Sl. No. |
Name of the Fund | Name of the Nominee | Relationship | D.O.B | ID / Ref No. | Share | Remarks |
|---|---|---|---|---|---|---|---|
| 1 | Death Cum Retirement Gratuity | 100% | |||||
| 2 | GPF/ZPGPF/CPS Final claim | 100% | |||||
| 3 | G.I.S Insurance and Savings Fund | 100% | |||||
| 4 | APGLI Final settlement | 100% | |||||
| 5 | EWF Fund benefits | 100% |