REPCO BANK EMPLOYEES PENSION FUND. Space for affixing attested passport size photograph

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Lucinda Green
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1 (RCB/Pension/12) REPCO BANK EMPLOYEES PENSION FUND FORM OF APPLICATION FOR GRANT OF FAMILY PENSION ON THE DEATH OF AN EMPLOYEE / PENSIONER (To be submitted in duplicate) Space for affixing attested passport size photograph 1. Name of the Applicant 2. Full Postal Address of Applicant 3. Phone No. Landline with STD code Mobile 4. PAN No. (in capital letters) 5. id Relationship with the deceased Employee / Pensioner If the Applicant is a minor, name of the Guardian WIDOW / WIDOWER/ SON / DAUGHTER 8. Nature of Guardianship NATURAL GUARDIAN (Father or Mother) / LEGAL GUARDIAN (appointed by Court) (In case of Legal Guardianship attested copy of Court Order to be enclosed) Page 1

2 9. Details of surviving widow / widower and children of the deceased Employee / Pensioner : Sl. No Name Relationship with the deceased Employee / Pensioner Date of Birth Marital Status If employed, name of the Employer & salary drawn p.m. (only in case where Son / Daughter is the Applicant) Details of the deceased Employee / Pensioner : a. Name b. Emp. No. 10 c. Designation at the time of death of the employee d. Date of death e. Branch/Office in which last worked f. Details of liabilities of the deceased employee / pensioner, if any, at Pension disbursing branch A/c No. Liability 11. Enclosures (tick whichever is applicable) a. Copy of death certificate b. Copies of proof of Date of birth of children c. 2 passport size photographs of Applicant / Guardian (wherever applicable) in addition to photo affixed to the application d. Declaration regarding Re-marriage / Marriage e. Declaration of Employment (where applicant is Son / Daughter) Page 2

3 12 Details of applicant s SB A/c at Repco Bank: Branch Name : Branch Code : SB A/c No. Date : (Left hand thumb impression in case of illiterate) Attesting Official's Signature : Name : Emp. No. : Designation : Seal : Branch/Division : Witness Signature : Name & Address : NOTE: Attestation and witness should be by an Officer of RepcoBank or a Gazetted Government Servant or two respectable persons in the Town/Village where the applicant resides. Application forwarded to Employees Pension Fund for sanction of Family Pension. Remarks if any: Manager/Dept. Head Pension Disbursing Branch (In case of death after retirement)/ Branch Member attached (In case of death while in service) Page 3

4 (RCB/Pension/13) DECLARATION REGARDING RE-MARRIAGE / MARRIAGE I hereby declare that I have not got re-married as on date and I undertake to report such an event promptly to the Repco Bank [Employees ] Pension Fund / Repco Bank branch through which I am drawing family pension. (Applicable only for widow / widower) I hereby declare that I have not got married as on date and I undertake to report such an event promptly to the Repco Bank [Employees ] Pension Fund / Repco Bank branch through which I am drawing family pension. (Applicable only to unmarried children) I declare that, to the best of my knowledge and belief, the above is correct. Date : (Left hand thumb impression in case of illiterate) Name : Attesting Official's Signature : Name : Emp. No. : Designation : Seal : Branch/Division : Witness Signature : Name & Address : NOTE: Attestation should be by an Officer of Repco Bank or a Gazetted Government Servant or a respectable person in the Town/Village where the applicant resides.

5 (RCB/Pension/14) DECLARATION ON EMPLOYMENT [Only in case where Applicant is Son/Daughter of the deceased Employee/Pensioner] I. Sri/Smt.... Son/Daughter of late Sri/Smt... hereby declare that I have been employed in M/s (Name of the Employer & address) as..... (designation) drawing Rs.. as salary per month. OR II. I am Self-employed and earning Rs. as income per month. I declare that, to the best of my knowledge and belief, the above are correct. Date : (Left hand thumb impression in case of illiterate)

EASTERN POWER DISTRIBUTION COMPANYOF AP LIMITED

EASTERN POWER DISTRIBUTION COMPANYOF AP LIMITED FORM OF APPLICATION FOR SERVICE PENSION/ FAMILY PENSION/ RETIREMENT GRATUITY/ SERVICE GRATUITY/ COMMUTATION (To be furnished in triplicate) Part I Information