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1. Name _______________________________
2. Date of Birth_____________________
3. Address # Tele No: _______________________ _______________________________________________________________
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# Original Native State ________________ # Proficiency in Gujarati __________ (Yes or No)
4. Particular of Husband:
# Date of Birth (Husband) ___________ # Date of Death (Husband) ___________
No. ___________________ Date of enrollment _______________________
Rank __________________ Date of discharge _______________________
Name ___________________ Discharge book No. & date __________________
Decoration ______________ Regt/Corps ____________ PPO NO. & date __________
Religion _______________________ Caste ________________________
5 Details of Husband's death :
War/Operation _____________________ Attributable _________________________
Non Attributable _____________________ After retirement ______________________
6. Details of family (only dependent children upto 25 yrs and dependent parents of deceased ex-Servicemen)
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Name
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DOB
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Relationship
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Educational Qualification
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7. Amount of family pension
Ordinary Rs. ____________________ Special Rs. ________________________
Liberalised special family pension Rs. ________________________________
8. Lump sum payment received:
(by her & husband)
Gratuity Rs. ________________________ Group Insurance Rs. ________________
Encashment of leave Rs. __________________________________
Financial Assistance Rs. __________________________________
Commuted Pension Rs. ___________________________________
9. Present Occupation and monthly income:
Service Rs. ______________________Business/Industry Rs. ____________________
Agriculture Rs. _____________________ Un-employed ________________________
10. Other relevant Information, if any ______________________________________
11. Identification Mark: __________________________
12. Left thumb impression ________________________
DECLARATION
I hereby declare that the particulars given above are true to the best of my knowledge and belief.
Date:
Place: (Signature of the Applicant Widow of Ex-serviceman)
VERIFICATION
The above Widow falls in the category of ex-Serviceman’s widow. The Identity Card No GUJ/0__ / ______ Dated__________ is prepared for issue to the individual after due verification & signature or the DSWRO.
The category of the widow is (Tick Appropriate category):-
- War –Op Widow
- Attributable Military Service (Died while in Service)
- Non Attributable Military Service (Died while in Service)
- Widow of ESM died after Retirement
Date:
Place: (Signature of staff verifying Details & preparing ID card)
COUNTER SIGNED
Date:
Place: (Signature of DSWRO)
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