SOU TH EASTERN R AILWA Y

DECLARATION FORM FOR PASS & PTO’S

Employee No : _____________________________ Bill Unit No : _________________________

Name of the Employee : ________________________________________________________________

Designation : _____________________________ Aadhar No : _________________________

Marital Status : Married/ Un-Married/ Divorce/ Widow/ Widower

Department: _____________ Working Unit: ____________________ Scale of Pay: _____________

Date of Birth: ____________ Date of Appointment: _____________ Class of Pass & PTO entitled: ______

Family & Dependent for whom the Passes & PTO’s are admissible in terms of IRCA Pass Rule
Sl Date of
Name Relationship Sex Identification Marks
No Birth
01

02

03

04

05

06
I certify that the above entries are correct

Enclosure: Birth Certificate

Date:

___________________________
Signature of Employee
____________________________
Signature of the Sub-Ordinate I/C
with Office Seal

Forwarded to _____________________ (Pass Section) ______________________________________

For information and necessary action please

____________________________________
Signature of the head of the Department
 FORM 6 (Pension/ NPS)
Stat ement showing the details of m embers of family for
purpose of Family Pension Schem e – 1964/ Appointed on or
after 01/01/2004
Name (Block Letters): ___________________________________________________________________

Father’s Name/ Husband’s Name: __________________________________________________________

Designation: _________________ Branch : _______________________Office: _____________________

Date of Birth: ________________________________ Date of Appointment: _______________________

Details of family: (Passport sizes Photograph of each Family Members to be affixed against each name)

Relationship Date of
Two identification
Sl Name & LTI of the with the Birth (by Passport size
Marks to each
No Family Member Railway Christian Photo
members
Servant Era) & Ref

01

02

03

04

05

06

And so on (If more than five members, please attach additional page as per the above proforma)
*Employee should put his/ her signature/ LTI on each photo of the family members in such a manner that appears
partially on the photo and partially on the paper outside the photo.
 I do hereby declare that the particulars given above are true and concept to the best of my behalf and
knowledge and I will be liable for Disciplinary action under RS (D&A) Rules 1968 for any particulars found
false later on as well as I will be responsible for its consequence.
I also declare that I have not violated Rules – 21 of RSCR – 1966 regarding marriage.
*(Strike out where it is no applicable)
Station: Kharagpur
Date:
Signature of the Employee
Full name (Block Letter) :
Designation :
Office/ Department :
Employee No./ PRAN No :

Countersigned Witness
Signature with Date :
Full Name (Block Letter) :
Designation :
Office/Department :

Declaration of Spouse

I do hereby declare that particulars above by my husband/ wife are true and correct to the best of my
belief and knowledge.
Signature of the Spouse
Witness
Signature with date: Name of the Spouse (Block Letters):
Full Name (Block Letter): Signature of the Employee:
Designation: Name (Block Letters):
Office/ Department: Designation:
Office/ Department:
Employee No/ PRAN No:

Countersigned

(Strike out which it is not applicable)

Station: Kharagpur
Date:

Head of Office/ Accounts Officer