Government of West Bengal
JAI BANGLA PENSION SCHEME
Affix Self-Attested
APPLICATION FORM Passport Size
(To be filled in English Block Capital Letters Only)
Photograph
(Please Check Appropriate Boxes, wherever applicable)
(* Marked fields are mandatory)
APPLICATION FOR (Please check Only One Box)
1 Taposili Bandhu (for SC)
2 Jai Johar (for ST)
3 Manabik
4 Old Age Pension X
5 Widow Pension X
6 Farmers’ Old Age Pension X
7 Old Age Pension for Fishermen X
8 Old Age Pension for Artisans and Handloom Weavers X
9 Lok Prasar Prakalpa X
PERSONAL DETAILS
First Name Middle Name Last Name
Beneficiary Name*
Gender* Male Female Others
Date of Birth* D D / M M / Y Y Y Y
Age as on 01/01/2020 Years
First Name Middle Name Last Name
Fathers’ Name*
Mothers’ Name*
Caste* SC ST
Marital Status* Unmarried Married Separated
Widow Widower
First Name Middle Name Last Name
Spouse Name, if
applicable
Monthly Income
Monthly Family Income
(Rs.)*
PERSONAL IDENTIFICATION NUMBER(S)
Digital Ration Card No.*
AHL TIN
Aadhaar No., if available
EPIC/Voter Id. No.*
PAN, if available
BPL Seq. No., if available
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BPL Id. No., if available
BPL Total Score, if available
CONTACT DETAILS
State* W E S T B E N G A L
Assembly Constituency*
District*
Police Station*
Block/Municipality/Corp.*
GP/Ward No.*
Village/Town/City*
House / Premise No.
Post Office*
Pin Code*
Number of Years Dwelling in West Bengal* Years
Mobile Number*
Email Id., if available
BANK ACCOUNT DETAILS
Bank Name*
Bank Branch Name*
Bank Account No.*
IFS Code*
FOR MANABIK SCHEME (To be filled in as per Disability Certificate Issued to the Applicant)
Type of Disability* (Please check Appropriate Boxes)
1 OH [Orthopedically Handicapped]
2 VH [Visually Handicapped]
3 HH [Hearing & Speech Handicapped]
4 MI [Mentally Illness]
5 MR [Mental Retardation]
6 MD [Multiple Disabilities]
7 LC [Leprosy Cured]
8 NR[Nervous Disorder]
9 OT[Others]
Percentage of Disability* . %
Certifying Authority *
ENCLOSURE LIST (SELF ATTESTED COPIES) (Please check Appropriate Boxes)
1 Passport Photograph
2 Copy of Caste Certificate
3 Copy of Digital Certificate from Appropriate Authority
4 Copy of Digital Ration Card
5 Copy of Aadhaar Card, if available
6 Copy of Voter Id
7 Copy of Residential Certificate (Self Declaration)
8 Copy of Income Certificate (Self Declaration)
9 Copy of Bank Pass Book
10 Others, please specify
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SELF DECLARATION
In the event of my death, I hereby nominate :
……………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………(Please mention Name,
Address & Relationship) to receive the rest amount payable to me till my death.
I give / do not give consent to the use of the Aadhaar No. for authenticating my identity for social security
pension (in case Aadhaar No. is provided by the Applicant).
Presently, I am receiving following pension(s) from Central Govt. / State Govt. / Local Administration / Govt.
Aided Organization (in case the Applicant is receiving pension from any other source):-
1. ……………………………………………………………………………………………………………………………………………………………….
2. ……………………………………………………………………………………………………………………………………………………………….
Presently, I am receiving the following social Security Pension/s (Please tick)
NSAP Old Age NSAP Widow Pension NSAP Disability Pension Old Age Pension
Widow Pension Disability Pension Lok Prasar Prakalpa Fisherman’s Old Age Pension
Farmers Old Age Pension Artisan/Weaver Old Age Pension
Date: (Signature of Applicant)
FOR OFFICE USE ONLY
Acknowledgement No.
Acknowledgement Date D D / M M / Y Y Y Y
Application Id.
Enquiry Officer Name
Enquiry Officer Designation
Enquiry Officer Mobile No.
Date: (Signature with Stamp of Enquiry Officer)
Recommending Authority Name
Recommending Authority Designation
Recommending Authority Mobile No.
COMMENTS:-
Date: (Signature with Stamp of Recommending Authority)
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