FORM REGARDING EMPLOYMENT TO DEPENDENTS OF ...

FORM REGARDING EMPLOYMENT TO DEPENDENTS OF EMPLOYEES DYING WHILE INSERVICE/MISSING FOR MORE THAN TWO YEARSPART-I1.(a)(b)(c)(d)(e)(f)(g)2.(a)(b)(c)(d)Name of the deceased/missing Govt. employee.Designation of the employee.Date of birth of the employee.Date of death/date from which missing.Total length of service rendered.Whether permanent or temporary.Whether belonging to SC/STName of the candidate for appointment.His/her relationship with the employeeDate of Birthwhether any other dependent has been appointed oncompassionate grounds.(e)Post for which employment is sought.3 Particulars of total assets left including amount of(a) Family pension(b)(c)(d)(e)D.C.R. GratuityL.I.C. Policies (including PLI)G.P.F. BalanceMovable and immovable properties and annual income earnedtherefrom by the family.(f)(g)(h)H.P. Employees Group Insurance amountEncashment of leave.Any other assets.Total4. Brief particulars of liabilities, if any.5. Had your husband/father taken any loan/ advance from the Government?If so, in the event of employment being provided to you, do you undertaketo refund the entire remaining unpaid amount of the loan or advancetogether with the interest to the Government and for this purpose are youprepared to give an undertaking on non-judicial paper of Rs. 3/-.6. Particulars of all the dependents of the Govt. servant (ifsome are employed, their income and whether they areliving together or separately):-Sr. No. Name and age Relationship with the Employed or not particulars ofGovernment servant the employment and emoluments._____ __________________ _________________ ____________________________12.3.4.5.

7. DECLARATION.I hereby declare that the facts given by me above, are to the best of my knowledge, correct. If any of thefacts herein mentioned are found to be incorrect/false at future date, my services may be terminated.I also undertake to refund the entire amount of loan/advance taken from the Government by myhusband/father in the event of employment being provided to me together with the interest on the loan/advace.Dated:-Signature of the candidate.Address:-Shri/Smt./Miss__________________________________ is known to me and the facts mentioned by him arecorrect.Signature of the permanentGovernment Servant.Name___________Address:-I have certified that the facts mentioned by the candidate abvove are correct.Signature of the Head of OfficeNameAddress:-