Annexure-XXII

For Annexure –A the following Form-A shall be substituted.

ANNEXURE- A (See rule 8 (i) (a)

FORM OF APPLICATION FOR APPOINTMENT UNDER THE REHABILITATION ASSISTANCE SCHEME (TO BE SUBMITTED IN DUPLICATE.)

PART-I

1 Name of the deceased Government servant.

2 Designation and office/Department of the

Government servant.

3 Whether permanent or temporary.

4 Total length of service rendered.

5 Date of death(enclose an attested copy of the

death certificate issued by the Health

& Family welfare Department.

6 List of family members as per the legal heir

certificate issued by the concerned Tahasildar.

7 Income and status of each of the legal heirs.

8 Is any of the members listed under item 6 has

been appointed under compassionate ground.

If so, give particulars of such appointment.

9 Total assets of the deceased Government servants.

a) Details of immovable property if any, in the name

of deceased Government servant and members of family.

b) Movable property.

c) Pension, family pension and TI etc.

PART-II

10 Name of the candidate for appointment.

11 His/her relationship with the deceased

Government servant

12 Date of birth.

13 Particulars of Educational/technical qualification and

experience, if any.

14 Whether belongs to any of the following categories

a) SC./S,T

b) Ex/Servicemen.

c) Physically handicapped.

d) Sportsmen.

15 The post applied for

I. Shri/Smt/kumari……………………………son/daughter/wife of shri…………………………….hereby declare that the information furnished above is true to the best of my knowledge and belief. If any of the facts herein mentioned are found to be incorrect or false at the future date my service can be terminated by the appointing authority without furnishing notice or reasonable opportunity of hearing

Date Signature of the applicant.

PART-III

Forwarded to Collector ……………………….for enquiry and report whether the family of the deceased Government servant is in distress financially.

Appointing Authority

(Seal & designation.)