Proforma Regarding Employment Of Dependents Of Government

PROFORMA REGARDING EMPLOYMENT OF DEPENDENTS OF GOVERNMENT SERVANTS DYING WHILE IN SERVICE/RETIRED ON INVALID PENSION
PART – A

I. (a) Name of the Government servant (Deceased/retired on medical grounds).
(b) Designation of the Government servant.
(c) Whether it is Group ‘D’ or not? (d) Date of birth of the Government servant. (e) Date of death/retirement on medical
grounds. (f) Date of initial appointment in Govt. service
innodeecosed/retired govt. servant. (g) Total tength of service tendered. (h) Whether permanent or temporary.
(i) Whether belonging to SC/ST/OBC II. (a) Name of the candidate for appointment.
(b) His/her relationship with the government servant.
(c) Date of birth.
(d) Educational Qualifications.

(e) Whether any other dependent family member has been appointed on compassionate grounds.

III.

Particulars of total assets left including

amount of:

(a) Family pension

(b) D.C.R. Gratuity

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(c) G.P.F. Balance

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(d) Life Insurance Policies (including Postal Life Insurance)

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(e) Movable and immovable properties and annual income earned there from by the family.

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(f) C.G.E., G.I.S. insurance amount & Saving amount

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(g) Encashment of leave

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(h) Any other assets

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Total __________________________

IV.

Brief particulars of liabilities, if any.

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V. S.No.

Particulars of all dependent family

members of the Government servant

(if some are employed, their income

and whether they are living together

or separately)

Name(s)

Relationship Age

with the

Government

servant

(1)

(2)

1.

2.

3.

4.

5.

(3)

(4)

Address (5)

Employed or not (if employed particulars of employme nt and emoluments)
(6)

VI.

DECLARATION/UNDERTAKING

1. I hereby declare that the facts given by me above are, to be best of my knowledge, correct. If any of the facts herein mentioned are found to be incorrect or false at a future date, my services may be terminated.

2. I hereby also declare that I shall maintain properly the other family members who were dependent on the government servant/member of the Armed Forces mentioned against I(a) of Part-A of this form and in case it is proved at any time that the said family members are being neglected or not being properly maintained by me, my appointment may be terminated.

Date:

Signature of the candidate Name: _____________ Address: _____________
_____________

Shri/Smt/Kum________________________________________ is known to me and the facts mentioned by him/her are correct.

Date:

Signature of permanent Government servant Name: _____________ Address: _____________
_____________

I have verified that the facts mentioned above the candidate are correct.

Date:

Signature of the Welfare Officer Name: _____________ Address: _____________

PART – B
(TO BE FILLED IN BY OFFICE IN WHICH EMPLOYMENT IS PROPOSED)

I. (a) Name of the candidate for appointment

(b) His/Her relationship with the government servant

(c) Age (date of birth), educational qualifications and experience, if any

(d) Post for which employment is proposed and whether it is Group ‘C’ or ‘D’.

(e) Whether there is vacancy in that post within the ceiling of 5% prescribed under the
scheme of compassionate appointment.

(f) Whether the post to be filled is included in the Central Secretariat Clarical Service or not.

(g) Whether the relevant Recruitment Rules provide for direct recruitment.

(h) Whether the candidate fulfils the requirements of the Recruitment Rules for
the post.

(i) Apart from waiver of Employment Exchange/Staff Selection Commission
procedure what other relaxations are to be given.

II.

Whether the facts mentioned in Part-A have

been verified by the office and if so,

indicate the records.

III.

If the Government servant died/retired on

medical grounds more than 5 years back,

why the case was not sponsored earlier.

IV.

Personal recommendation of the Head of

the Department in the Ministry/Department/

Office.

(With his signature and office stamp/seal).

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