Get Form 12 See Rule 77 2

FORM 12 See Rule 77 2 Form of application for the grant of death graduity on the death of a Government servant. To be filled in separately by each claimant and in case the claimant is minor the form should be filled in by the guardian on his/her behalf* i Name of the claimant in case he is not minor ii Date of birth of the Claimant 2. i Name of the guardian in case the claimants are minors 3. i Name of the deceased Government servant in respect of whom gratuity is being claimed ii Date of death of Government servant iii Office/Department/Ministry in which the deceased served last 4. Relationship of the claimant/guardian with the deceased Government servant 5. Full postal address of the claimant/guardian 6. i Where the gratuity is claimed by the guardian on behalf of minors the names of the minors their ages relationship with the deceased Name Age Relationship with the servant Postal address 7. Places of payment of Pension and gratuity Signature / Thumb mpression of the claimant/guardian 8. Two specimen signatures or Ist left hand thumb and finger impressions of the claimant/guardian duly attested To be furnished in a separate sheet duly signed by 2 witnesses. 9. Attested byName Full Address Signature i ii 10. Witnesses 1. To be furnished in case the applicant is not literate enough to sign his name. 2. Attestation should be done by two Gazetted Government Servants or two or more persons of respectability in the town village or Pargana in which the applicant resides. To be filled in separately by each claimant and in case the claimant is minor the form should be filled in by the guardian on his/her behalf* i Name of the claimant in case he is not minor ii Date of birth of the Claimant 2. i Name of the guardian in case the claimants are minors 3. i Name of the deceased Government servant in respect of whom gratuity is being claimed ii Date of death of Government servant iii Office/Department/Ministry in which the deceased served last 4. i Name of the guardian in case the claimants are minors 3. i Name of the deceased Government servant in respect of whom gratuity is being claimed ii Date of death of Government servant iii Office/Department/Ministry in which the deceased served last 4. Relationship of the claimant/guardian with the deceased Government servant 5. Full postal address of the claimant/guardian 6. Relationship of the claimant/guardian with the deceased Government servant 5. Full postal address of the claimant/guardian 6. i Where the gratuity is claimed by the guardian on behalf of minors the names of the minors their ages relationship with the deceased Name Age Relationship with the servant Postal address 7. i Where the gratuity is claimed by the guardian on behalf of minors the names of the minors their ages relationship with the deceased Name Age Relationship with the servant Postal address 7. Places of payment of Pension and gratuity Signature / Thumb mpression of the claimant/guardian 8. Two specimen signatures or Ist left hand thumb and finger impressions of the claimant/guardian duly attested To be furnished in a separate sheet duly signed by 2 witnesses.