Appendix ‘E’
REGISTRATION FORM-WIDOWS/WAR WIDOWS OF EX-SERVICEMEN

Name of applicant ___________________________________________ Photo
Date of birth/Age ___________________________________________
Address ___________________________________________________
__________________________________________________________
Tehsil or Police Station ______________________
Tel_________________________________
Service particulars of husband:
Name : ____________________________________No. __________________________
Rank_____________________________ Date of Birth __________________________
Date of Enrolment _________________ Date of Death __________________________
Date of Discharge __________________ Discharge Book No ______________________
PPO No. _______________________________________________________________
Decoration__________________________ Regt/Corps __________________________
Death Details of husband :
War/Operation in which died _______________________________________________
Attributable _____________________________________________________________
Non-Attributable _________________________________________________________
After Retirement _________________________________________________________
Details of family ( only dependent children upto 25 years and dependent parents of deceased Ex-servicemen )
Name Age Relationship Educational
Qualification
i)
ii)
iii)
iv)
Amount of family pension OrdinaryRs _________________Special Rs ______________
Liberalised special family pension Rs. _______________________
Lump sum Payment Received :
(By her & husband)
Gratuity Rs. __________________________Group insurance Rs.______________________
Encashment of Leave Rs. ______________ Financial Assistance Rs.___________________
Commuted Pension Rs. ________________
Present occupation and monthly Income
Service Rs. __________________________ Business/Industry Rs.___________________
Agriculture Rs. _______________________
Unemployed__________________________
Other relevant Information, if any ________________________________________________
____________________________________________________________________________
Identification Mark:
___________________________________________________________
Left Hand Thumb
Impression:____________________________________________________

DECLARATION
I hereby declare that the particulars given above are true to the best of my knowledge and belief
Date: ____________________
Place: ____________________ (Signature of Applicant)
--------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE
Status as widow Yes/No
Category: War widow___________________
Attributable___________________
Non Attributable_______________
After Retirement_______________
Identity Card Issued to Late Ex-servicemen _________________________
No. & Date of identity Card Issued_________________________________
Date: ______________________
Place: ______________________
(Signature of Secretary
RSB/ZSB
with Office stamp & date)