Application for ex.Gratia Grant /Other Facilities.

Application for the family of Late Sh.________________________ Employed as ___________________

____________________ in Food & Supplies Dept.Pb.S.A.S.Nagar in the Deptt. Office of _______________
____________________.
1 Name and the full address
of the applicant.

________________________________________________
________________________________________________

2 Relationship to the deceased

Govt.employee.

________________________________________________

3 Circumstances of death of
Govt employee.

________________________________________________

4 Name and age of suriviver and relationship of the deceased.

No.

Name

Age

Relationship

5 Unmarried daughters.

__________________________________________________

6 Widow daughters.

__________________________________________________

7 Parents wholly dependent only

On deceased Govt.employee.

__________________________________________________

8 Any other relevant in-formation.

__________________________________________________

9 The treasury from which on Gratia

Grant to be drawn.

___________________________________________________

Dated
Signature of the Applicant.
Address.