204 THE GAZETTE OF INDIA : EXTRAORDINARY [P ART II SEC.
3(i)]
FORM 10
[See rules 50, 71 , 74, 76, 79 and 80 ]
Application to the Head of Office for Family Pension on Death of a Government Servant or Pensioner or on Death
or Ineligibility of a Family Pensioner or when a Government Servant or Pensioner or Family Pensioner goes missing
Photograph
Application for family Pension on : (Tick one box)
Death of Government Death of Pensioner Death of Family Pensioner Ineligibility of Family
servant Pensioner
Disappearance of Disappearance of Disappearance of Family Pensioner
Government servant Pensioner
1. Details of deceased/missing Government Servant/Pensioner (To be filled only if a Government
servant/pensioner has died or gone missing)
Name Office/Dept./Ministry Nationality
Date of Date of death (in Date from which missing
retirement (in case of death of (in case of missing
case of Government Government servant/
pensioner) servant/pensioner pensioner)(DD/MM/YYYY)
(DD/MM/YYYY) (DD/MM/YYYY)
Date of lodging of PPO No. (If issued)(in case of
report with Police (In pensioner)
case of missing
Government
servant/pensioner)
(DD/MM/YYYY)
2. Details of previous family pensioner who has died or become ineligible or gone missing (To be filled
only if a family pensioner has died or become ineligible or gone missing):
*Name of deceased *Office/Dept./Ministry *Nationality
Government
servant/ pensioner
*Date of retirement *Date of death of *PPO No. (Issued
of Government Government servant/ on retirement/
servant pensioner death of
(DD/MM/YYYY) (DD/MM/YYYY) Government
servant )
Name of previous Date of Date from which
family pensioner death/ineligibility of missing (in case of
who has previous family missing family
died/become pensioner pensioner only)
ineligible or gone (DD/MM/YYYY) (DD/MM/YYYY)
missing
Date of lodging of report with PPO No. sanctioning family pension
Police (In case of missing to previous family pensioner who
family pensioner) has died or become ineligible or
(DD/MM/YYYY) gone missing
[ II 3(i)] 205
Note: The information for items marked ( *) is to be given in respect of the person who was employed in
the Department and on whose death, family pension was originally sanctioned. Remaining information
is to be given in respect of deceased/ineligible/missing family pensioner.
3. Details of claimant:
Name Date of birth Aadhaar No.
(DD/MM/YYYY) *(Voluntary)
PAN Relationship with deceased/missing Govt.
servant/pensioner
If the claimant is a If the claimant is a divorced daughter If the claimant is a
widowed daughter, date Date of filing of divorce disabled
of death of husband of petition child/sibling, date
the claimant (DD/MM/YYYY) from which
(DD/MM/YYYY) Date of divorce suffering from the
(DD/MM/YYYY) disability
(DD/MM/YYYY)
4. Postal address:
Flat/House No./Bldg. Name Street/Locality
Village & Post Office/Block City & District
State Pin Code
Telephone /Mobile No. E-mail ID
5. In case the claimant is minor or suffering from disorder or disability of mind, including mental retardation,
details of guardian/ nominee, wherever applicable:
Name Date of Birth Aadhaar No.
(DD/MM/YYYY) *(Voluntary)
PAN Relationship with minor/ mentally disabled claimant
Relationship with the deceased /missing Government
servant /pensioner
Postal address:
Flat/House No./Bldg. Name Street/Locality
Village & Post Office/Block City & District
State Pin Code
Telephone /Mobile No. E-mail ID
6. Details of Bank:
A/c No.
IFS Code
7. Indicate whether family pension is also admissible from any other source- (Tick whichever is applicable)
Military
State Govt.
Public sector undertaking/ autonomous body/ local fund under the Central or State Govt.
8. Are there any criminal proceedings pending against the claimant? If so, give details. ...................................
9. Are there any charges of fraud or any other serious crime against the missing Government servant/
pensioner/family pensioner ? If so give details. (Applicable in case of missing Government servant/pensioner/family
pensioner) ......................................................
I declare that the information given by me is true to the best of my knowledge and nothing has been concealed
therefrom.
I am aware that future good conduct of the claimant/family pensioner shall be an implied condition for every grant of
family pension and its continuance.
[
Place:
DD MM YYYY
Date: (Signature of the claimant/guardian)
206 THE GAZETTE OF INDIA : EXTRAORDINARY [P ART II SEC. 3(i)]
*Providing Aadhaar No. is voluntary. However, if it is provided, consent to link it to bank account and also for
authentication of identity from UIDAI for pension related purpose only, is presumed.
Note: If a member or members of family is/are proposed to be co-authorised for family pension, an application in
Form 8 may be attached. In accordance with Rule 63(1), the following members of family are eligible for co-
authorisation for family pension along with spouse, if there is no other member of family eligible for family pension
before them:
Disabled child/ children
Dependent parents.
Disabled siblings.
List of Documents to be submitted with Form 10
1. Two specimen signatures (to be furnished in a separate sheet) .If the claimant cannot sign his/her
name then he/she is required to put the impression of his/her left/right thumb etc. on the document in
lieu of specimen signature.
2. Proof of identity.
3. Proof of relationship with the deceased/missing Government servant/pensioner
4. Two copies of self attested passport size photographs of the claimant.
5. Details of family in Form 4.
6. Undertaking for refunding any excess payment made by the pension disbursing bank in Format 9.
7. Certificate(s) of age showing the dates of birth of the children. The certificates should be from the
municipal authorities or from the local panchayat or from the head of a recognized school or
Central/state board of education.
8. Two specimen signatures of guardian (to be furnished in a separate sheet if the claimant is minor or
suffering from mental disability)
9. If the guardian cannot sign his/her name then he/she is required to put the impression of his/her
left/right thumb etc. on the document in lieu of specimen signature.
10. A copy of Photo ID proof of the guardian along with proof of Permanent Address.
11. Two self attested copies of passport size photograph of the guardian/nominee
12. Copy of Pension Payment Order of previous pensioner/family pensioner.
13. Copy of death certificate of Government servant/pensioner/previous family pensioner , if applicable
14. Copy of document regarding ineligibility of previous family pensioner, if applicable
15. Copy of report lodged with police in respect of missing Government servant or pensioner or previous
family pensioner.(In case of missing pensioner/family pensioner only)
16. Copy of the report from the police that the Government servant could not be traced so far despite all
efforts made (In case of missing pensioner/family pensioner only)
17. Indemnity Bond in Format 8 (In case of missing pensioner/family pensioner only)
18. Last Income Tax Return failing which Certificate from SDM failing which any other document regarding
income in support of the claim for family pension (Not applicable in the case of spouse).
19. Copy of the first page of the Pass Book showing name and account number in which the family pension
is to be credited. (Name of the claimant in the form and in the bank account should be the same)
20. If the claimant is a widowed/divorced daughter or a disabled child/sibling, document in support of the
eligibility of the claimant (i.e death certificate of husband in the case of widowed daughter/divorce
decree in the case of divorced daughter/disability certificate in the case of a disabled child)
21 Form 8, if a family member is proposed to be co-authorised for family pension.