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.)