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Pass Declaration Form-1

This document is a declaration form for employees of the Ahmedabad Division of Western Railway to request passes or PTO for their family members and dependent relatives for a specified year. It requires personal and employment details of the employee, as well as information about family members and dependents, including their relationship, date of birth, and Aadhaar card numbers. The form also includes a declaration regarding the dependency status of relatives and notes restrictions on post-retirement complimentary passes.

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Ravi kumar
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16 views1 page

Pass Declaration Form-1

This document is a declaration form for employees of the Ahmedabad Division of Western Railway to request passes or PTO for their family members and dependent relatives for a specified year. It requires personal and employment details of the employee, as well as information about family members and dependents, including their relationship, date of birth, and Aadhaar card numbers. The form also includes a declaration regarding the dependency status of relatives and notes restrictions on post-retirement complimentary passes.

Uploaded by

Ravi kumar
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

AHMEDABAD DIVISION-WESTERN RAILWAY

Declaration for issue of Passes/PTO to family and dependant relative of employee


For the year -

Affix family photo


entitled for pass with
attestation of unit
incharge 2 X 3” size

Name : Design :
PF NO. : Date of Appointment :
Department : Scale of Pay/Level :
Basic Pay : Mob no. :
Details of family members and dependent relatives entitled for Pass:-
Name of Family members Relationship/ Date of Educational
Sr. No. and Dependant relatives Married/unmarried Birth Age qualification Aadhaar card no.
1.
2.
3.
4.
5.
6.

Details of all family members:-


Name of Relationship/ Date of Educational
Sr. No. Family members Married/unmarried Birth Age qualification Aadhaar card no.
1.
2.
3.
4.
As regards dependant relative, I hereby declare that he/she is:
1. Fully dependant on me as my father is not alive and he/she resides with me.
2. Not serving anywhere and does not receive any pension from State or Central Govt.
“Provided that a person shall not be considered to be dependent relative if his/her monthly income from all sources
including pension, dearness relief etc., exceeds 15% of the basic pay of the Railway servant or the amount arrived at by
adding minimum pension/family pension of Rs.9000/- (excluding the element of additional pension to old pensioners)
and the dearness relief admissible to the pensioner/family pensioner thereon, rounded off to the nearest ten rupee
figure, whichever is more.” (RBE no.132/2016) The change in income will be advised immediately.
Note: - Dependants are not allowed in post retirement complimentary passes to be issued to retired employees.

Signature of the employee Signature of forwarding


(with date) Office Supdt/Supervisor
With stamp & seal

Residential address:-

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