HRMS
(PRCP)RETIRED EMPLOYEES
MANUAL PASS DECLARATION FOR WIDOWS (FAMILY PENSIONER) OF RAILWAY EMPLOYEES
1. Name of the Applicant (In BLOCK letters) :
2. Date of Birth of the Applicant :
3. Name of the employee (deceased) :
4. Designation of the employee (deceased) :
5. Name of the Office :
(where the employee was working prior to demise)
6. Date of demise of the employee :
7. Details of dependent children :
Srl. No Name Age as on relationship
8. Class of pass admissible (Demise/Retirement):
9. Present address :
10. Contact Number/Mobile Number :
Signature/Left Thumb Impression
of the widow
CERTIFICATE
(To be given by serving Railway employee)
Certified that the Signature of the information given above is Railway Employee correct to the best of
my knowledge and belief.
Signature of the Rly.Employee Signature of the Rly. Employee
Name : __________________ Name : __________________
Designation : ______________ Designation : ______________
Office: __________________ Office : __________________
Emp. No _________________ Emp. No __________________
Signature and designation of Attesting officer. Signature of issuing Authority
With Office stamp. With Office stamp.
Note :- 1. Attested photocopy of PPO Book. 2. Death Certificate photocopy.
(All Retired Staff are hereby requested filling above form and forward to Pass Clerk.)
