Application for the grant of special increment in the form of personal pay for promoting Small Family Norm by undergoing sterlisation operation on or after 04.12.79 (Authority : Bd's letter No.80/H(FW)7/1 of 7.2.80)

Employee's Name : Male/Female
Emp.No. :
Designation :
Office/Shop/T.No.:
Sterilisation done : Tubectomy/Vasectomy
Date of Operation: Hospital's Name:
Place of Hospital: Design. of the Doctor
issuing the certificate
Employee's Age:
Spouse's age:
Name of the Spouse: No.of living children:
Scale of pay: Pay drawn:
Date of next increment:
Rate of next increment: If spouse is employed in Govt./
Quasi Govt./Govt.Enterprises:
Designation: Place of Employment:

Address of the employer
of the spouse.

DECLARATION TO BE FURNISHED
---------------------------
1. I have undergone Vasectomy/Tubectomy sterlisation at the Hospital
2. My spouse Shri/Smt. has undergone Vasectomy/
Tubectomy sterlisation at the Hospital on
3. The necessary certificate issued by in the proforma prescribed in Board's letter no.80/H(FW)7/1 of 05.06.81 is enclosed.
4. In case recanalisation is resorted to by myself or by my spouse for any reasons whatsoever, I undertake to report this fact forthwith to the Government so that the payment of special increment sanction is stopped from the date of recanalisation.
5. I also certify that my wife Smt. is not pregnant on this date (applicable Tubectomy / Vasectomy only)
6. My spouse is not employed.
7. My spouse is employed as at the office of
I hereby declare that my spouse is not claiming the benefit of special increment in his/her office.
The declaration furnished by my spouse in this regard is enclosed (in dup.). The sanction of special increment to me may be advised to my spouse's employer and to the Accounts Officer concerned.
8. I declare further that I will not make a second claim for special increment if Vasectomy/Tubectomy is undergone by myself of by my spouse at a later date. My spouse also will not resort to this.
9. I also certify that the above particulars furnished by me are true and correct to the best of my knowledge.

Place:
Date: Signature of the employee.

Forwarding endorsement to be made by the supervisor:
----------------------------------------------------
In case Free pass is issued to the employee at his end
Emp.Name: Design: Emp.No.
Spouse Name & Age: No.of Living children:

The above particulars are furnished as per the pass
declaration furnished by the employee.
2. In case of others:-
The application is forwarded for further action.
Forwarded to by Dy.CPO/G /Dy.CPO/WS

Date: Signature of the forwarding official
with designation office/Shop.
DECLARATION TO BE FURNISHED
---------------------------
1. I have undergone Vasectomy/Tubectomy sterlisation at the Hospital

2. My spouse Shri/Smt. has undergone Vasectomy/
Tubectomy sterlisation at the Hospital on

3. The necessary certificate issued by in the proforma prescribed in Board's letter no.80/H(FW)7/1 of 05.06.81 is enclosed.

4. In case recanalisation is resorted to by myself or by my spouse for any reasons whatsoever, I undertake to report this fact forthwith to the Government so that the payment of special increment sanction is stopped from the date of recanalisation.

5. I also certify that my wife Smt. is not pregnant on this date (applicable Tubectomy / Vasectomy only)

6. My spouse is not employed.

7. My spouse is employed as at the office of
I hereby declare that my spouse is not claiming the benefit of special increment in his/her office.
The declaration furnished by my spouse in this regard is enclosed (in dup.). The sanction of special increment to me may be advised to my spouse's employer and to the Accounts Officer concerned.

8. I declare further that I will not make a second claim for special increment if Vasectomy/Tubectomy is undergone by myself of by my spouse at a later date. My spouse also will not resort to this.

9. I also certify that the above particulars furnished ny me are true and correct to the best of my knowledge.

Place:

Date: Signature of the employee.

Forwarding endorsement to be made by the supervisor:
----------------------------------------------------
In case Free pass is issued to the employee at his end
Emp.Name: Design: Emp.No.

Spouse Name & Age: No.of Living children:

The above particulars are furnished as per the pass
declaration furnished by the employee.

2. In case of others:-
The application is forwarded for further action.
Forwarded to by Dy.CPO/G /Dy.CPO/WS

Date: Signature of the forwarding official
with designation office/Shop