Scribd
Upload
3K views4 pages

Declaration of Family Members

This document contains a declaration form for an employee to request passes/PTOs for family members and dependent relatives according to IRCA conference rules. It lists the employee's personal details and provides spaces to fill in information for up to 7 family members and 4 dependent relatives, including their name, relationship to employee, age, and date of birth. The employee declares that the listed individuals reside with and are wholly dependent on the employee, and meet other criteria to qualify for passes/PTOs under the applicable rules.

Uploaded by

anandpunna
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
3K views4 pages

Declaration of Family Members

This document contains a declaration form for an employee to request passes/PTOs for family members and dependent relatives according to IRCA conference rules. It lists the employee's personal details and provides spaces to fill in information for up to 7 family members and 4 dependent relatives, including their name, relationship to employee, age, and date of birth. The employee declares that the listed individuals reside with and are wholly dependent on the employee, and meet other criteria to qualify for passes/PTOs under the applicable rules.

Uploaded by

anandpunna
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 4

DECLARATION OF FAMILY MEMBERS & DEPENDENT RELATIONS

FOR THE ISSUE OF PASSES/PTOs AS DESIRED IRCA CONFERENCE RULES. 1. 2. 3. 4. 5. 6. 7. Name of the employee (in full) Designation Date of Birth Date of Appointment Date of Retirement : : : : : B.SREENIVASULU. TRACKMAN. 01/07/1959. 21/09/1982. 30/06/2019.

Rate of pay & Scale (in RS (RP)97): Rs.11650/- (5200-20200-2000)

Date of entry into Gazetted cadre (in : respect of Officers). a) Date of transfer in this office (Rly.): Station/Office prior to transfer to this : Office/Railway. Previous Pass Account : Designation prior to transfer to this : Office/Railway. My father is alive : I am married/un-married : MARRIED. Details of family members dependent: relatives for whom Passes/PTOs are requested.

8. 9. 10. 11. 12. 13.

a) Family Members: S.No. Name (s) Relationship Age 1 JAYAMMA WIFE 46 2 B.CHANDRAKISHORE NATH SON Married 3 B.DHARINI UNM/Daughter 23 4 B.KAVITHA UNM/Daughter 21 5 6 7 8 Date of Birth 01/07/1965 19/05/1982 25/09/1988 16/08/1990

b) Dependent relatives: S.No. Name (s)

Relationship

Age

Date of Birth

Attendant (if any) Contd..2..

-: 2 :14. I hereby declare that all the above mentioned members are residing with me and wholly dependent upon me. 15. No brothers/sisters of mine working in the Railways are obtaining Privilege Passes/PTOs for the above dependent members. 16. The un-married daughters/sisters mentioned above, who are working in Railways are not availing Privilege Passes/PTOs in their accounts. 17. The above dependent as shown in B above are not having any independent source of income or more than 15% of my emoluments of Rs.2060/- per month whichever to more (inclusive of temporary increase in Pension and pension equivalent of on CRS benefits) from time to time.

Signature & Designation of Attesting Officer.

Signature of employee. Date:

Dependent members as defined under IRCA conference Rules:Family Members : Wife, husband, Un-married & Widowed daughters, Sons under 21 years Student, Spls 21 years & above, subject to on condition of bonafide certificates from the recognized education Institutes every Academic year in July.

Dependent Relatives: Applicable when father is not alive, widow mother, Un-married and Widowed sisters not having any brother 21 years above subject to production of bonafide certificate from the recognized education Institute every Academic year beginning in July. Attendents : Means employed on a salary in the personal service of the employee i.e. whole time domestic servant such as Cook, Ayah, but does not include Tutor, Dhoby etc. or any relative of the employee in the capacity of servant. : : : 2. Signature : Name : Designation

Witnesses: 1. Signature Name Designation

SOUTH CENTRAL RAILWAY Office of_____________________

P.F.No.:____________________ PASS A/C No.:_______________

DECLARATION OF FAMILY MEMBERS AND DEPENDENT RELATIONS FOR THE ISSUE OF PASSES/PTOs AS DEFINED IRCA CONFERENCE RULES
1. Name of the Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (In full) 2. Designation . . . . . . . . . . . . . . . . . . . . . . . .. Rate of Pay Rs. . . . . . . . . . . . . . . . . . 3. Scale Rs . . . . . . . . . . . . . . . . . . . . . . . . . .. Date of Birth . . . . . . . . . . . .. 4. Date of appointment . . . . . . . . . . . . . . . . . . .Date of transfer to . . . . . . . . . . . . . .. . 5. Date of entry into this office/Rly . . . . . . . . . . . . . . . . . . . . . . . . . .. Gazetted cadres. 6. Station/ Office period to transfer to . . . . . . . . . . . . . . . . . . . . . . . .. this office Rly. . 7. Previous pass Account maintained in the office of . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Designation period to transfer to this office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. My father is not alive . . . . . . . . . . . . . . . . . 10. I am married . . . . . . . . . . . . . . . . . . . 11. Details of family members/ dependent relatives for whom Passes / PTOs required. ....................................................................... SL.No. Name (A) Family members 1. 2. 3. 4. 5. 6. (B) Dependent relatives. 1. 2. 3. 4. Attendant (if any) Relationship age Date of Birth

DATE BIRTH TO BE FURNISHED INVARIABLE FOR SONS AND BROTHERS (YEARS AND ABOVE)

12. Hereby declare that all the above-mentioned members are residing with me and are Wholly dependent upon me. 13. No Brothers/Sisters of mine working in the Railway are obtaining privilege pass/PTO for the above dependent members. 14. The unmarried daughters/sisters mentioned above who are working in Railway are not availing privilege passes/ PTOs in their account. 15. The above dependents (as shown in B above) are not having any dependent sources of income or more than 15% of my employments or Rs.1275/-+DPper month whichever is more (inclusive of DCRG benefits) from time to time. Date : Signature of the Employee ( in full )

Signature Attested. Signature and Designation of Supervisor/Officer.

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy