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 Govt. 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 and 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 Servant: (a) Details of immovable property, if any, in the name of deceased Govt. Servant & members of Family : (b) Movable property: (c) Pension, Family Pension and T.I. etc.

P A R T – 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) S.C./S.T: (b) Ex-Serviceman: (c) Physically handicapped: (d) Sportsman : 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.

P A R T – III

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

Appointing Authority

(Seal & designation)

PART-IV

(Certificate by Collector of the District)

Certified that the information furnished by the applicant in this application form have been enquired into and found correct/ incorrect. The family of the deceased Government employee is in distress/ not in distress. The annual income of the family from all sources excluding Pension and T.I. is Rs. . . . . . . . . . . . ………………………..for the year, . . . . . . .. Forwarded to the . . . . . . . . . . . . . . . . . . (Appointing Authority)

COLLECTOR & DISTRICT MAGISTRATE

(No authority except the Collector & District Magistrate shall sign this certificate).