Documents required by DPDO, Shimla
1. Discharge book / Pension book / Identity Card.
2. Certificate from Gram Panchayat stating that you have not any kind of pension from any
other sources.
3. Character certificate from concerned Gram Panchayat.
4. Certificate from Gram Panchayat Pradhan regarding the pensioner not re-married since
the demise.
5. Two latest passport size photographs.
6. Revenue stamp.
7. LTA from bank / Bank draft
DESCRIPTIVE ROLL OF
Name : _______________________________________ HO No : _____________
Regimental No : ___________________ Rank : __________ Unit/Corps : _____________
Father’s Name : ____________________________________
Village : ______________________________ Post Office : _________________________
Tehsil : ______________________________ District : Bilaspur State : Himachal Pradesh
Height : ______________ Colour of hair/eyes __________________Comp : ___________
Face/Figure : ___________________ Religion : _______________ Caste/Tribe : ________
Length of Service before pension : _____________________________________________
Date of Birth : _______________ Age when pensioned : _______ Year _____Months______
Date of Commencement of pension _____________________ Type of Pension : _________
Period f grant of pension : _____________________________
PPO No : __________________________________________
Paying of station : ____________________________________________________________
Basic pension per month : Rs ________________ Channel of payment : _________________
Residual pension Rs ______________________ Bank Account No : ___________________
Name of Bank : _____________________________________________________________
Other pensionary benefits Rs _________________
Any other important information : _______________________________________________
Relief Rs __________________________________________________________________
Indelible identification marks : 1. ________________________________________
2. ________________________________________
Name of wife /’ husband : ________________________
Remarks on examination by DPDO
Next of kin or other person to whom arrears of ___________________________
Pension is to be paid at the demise of pensioner
___________________________
Name : ______________________________
(Signature of DPDO)
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Signature of pensioner : 1. ________________ 2. _________________3._______________
Thumb impression 1. ________________ 2. _________________ 3. _______________
of pensioner
Photographs of pensioner Photo of Sh/Smt _________________
Attested by Zila Sainik Welfare
Signa
ture
of
attesti
ng
Office
r
Dated : ______________ With seal.
Signature of two pensioners (grantors) to whom he is known as the individual of the pension
list.
Signature of Guarantor Name of HO No Home Address
DPDO
Vill :
1. __________________ PO :
Name: ___________________ Teh :
Distt :
Vill :
2. __________________
PO :
Name: ___________________
Teh :
Distt :
Completed by me Taken before __________________
Signature / Thumb impression of Signature & Designation of DPDO
Pensioner
FORM OF OPTION (FORMAT – F)
Smt/Miss/Mr ___________________________ widow/son/daughter/Mother/Father of Ex
No_______________ Rank ______________ Name __________________________ hereby
opted for:-
(a) The medical facilities from Armed forces hospitals/MI Room/ECHS.
OR
(b) Medical allowance of Rs 500/- per month as I am residing in area where no
armed forces hospital/MI Room (OPD Facility)/ECHS Hospital is available.
Present address :-
Vill/Mohalla : _____________________
PO : _____________________
Thana (PS) : _____________________
Teh : _____________________
Distt : _____________________
State : _____________________
(Signature of claimant)
ATTESTATION
Place : Zila Sainik Welfare
Date : any Competent authority
COUNTERSIGNED
Station : C/o 56 APO (Sig of OIC Record Officer)
Dated :
FORMAT – J
AFFDAVIT SWORN BEFORE A MAGISTRATE
(As per Annexure to the letter of GOl, MoD letter No 241/B/D(P/S)2001 dt 28 Aug 2001)
I, __________________________ (Name of the applicant) _________________
wife/husband/son/Daughter of Shri _____________________________ aged __________
years, resident of Village _________________ PO : ______________________ Teh :
_________________ and Distt:__________________ do hereby solemnly affirm and declare
as under :-
The deceased ________________________________________________ (Name of the
deceased service personnel) was my Husband/Father.
I was wholly dependent upon my late husband mentioned above, for pecuniary needs and
other basic necessities for my bare existence.
DEPONENT
VERIFICATION
I, the above said _______________________________________________ (Name of
applicant),
Do hereby solemnly affirm and declare that the facts mentioned above are true to the best of
my knowledge and belief and nothing has been concealed thereof.
Place :
Date : DEPONENT
DETAILS OF SAVING BANK ACCOUNT
1. Beneficiary Details :-
(a) Name and Contact Person : Sh/Smt_________________________
(b) Home address : Village : ______________________
PO : ______________________
Teh : ______________________
Distt : Bilaspur (HP)
(c) Contact No : _____________________________
2. Particulars of Bank Account :-
(a) Account Title : ___________________________________
(b) Name of the Bank : ____________________________________
(c) Name of the Branch : ____________________________________
(d) IFSC Code No : ____________________________________
(d) Address :-
(i) Village : _______________________
Post Office : _______________________
Tehsil : _______________________
District : Bilaspur (HP)
(ii) Telephone No : _______________________
(e) 9 Digit MICR Code Number of : _______________________
the bank and branch appearing on the
MICR cheque issued by the bank.
(f) Type of account (Saving or Current) : _______________________
(g) Account number (as appearing : _______________________
on the cheque book)
(Please attached a blank cancelled cheque original and photocopy of a cheque)
I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or
not effected at all for reasons of in complete or incorrect information. I would not hold the user institution
responsible. I have read the option invitation letter and agree to discharge the responsibility expected of me as a
participant under the scheme.
Dated : ____________________ (Signature of Account Holder)
Sh/Smt ____________________
Certified that the particulars furnished above are correct as per our records.
Dated : _________________ (Signature of Authority / Bank Manager)
With rubber stamp
COUNTERSIGNED
Place : ZSW, Bilaspur (HP) (Signature of Zila Sainik Welfare)
Dated : _________________ With office seal
FORM OF WITNESSES
1. Signature of the FIRST Witness : ___________________________
Name of the Pensioner : ___________________________
Regimental No : ___________________________
Rank : ___________________________
Records Office : ___________________________
H.O Number : ___________________________
Bank Branch : ___________________________
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2. Signature of the Second Witness : ___________________________
Name of the Pensioner : ___________________________
Regimental No : ___________________________
Rank : ___________________________
Records Office : ___________________________
H.O Number : ___________________________
Bank Branch : ___________________________
COUNTERSIGNED
