ࡱ> "[ e4bjbj 4ΐΐ,^T+.@@@*******$J,.*@"@@@*?*r"r"r"@R*r"@*r"r"V(@i")0 (_40/) **0+;)x/d/)/)@@r"@@@@@**N!$@@@+@@@@/@@@@@@@@@ : APPOINTMENT ON COMPASSIONATE GROUNDS DEATH CASES S&WIs REPORT Name of the candidate SexRelationship to the deceasedQualification Name of the ApplicantRelationshipPostal Address  Name of the deceasedDesignation & StationStaff No.P.F.No.Rate of PayDate of BirthDate of Appt.CommunityDate of DeathCause of DeathIV.Settlement Dues: P.F.D.C.R.G.SSSGISCELSWCAFamily Pension Rs.+ Relief for 7 yearsFamily PensionRs.+ Relief afterwardsV.Family Composition: Sl. No.NameRelationAge/D.O.B.Edu.Qln.Present EmploymentMarried/ Unmarried VI. Whether any of the dependents have already been appointed on compassionate ground. If so, details there of. VIII. General Remarks: It is hereby certified that no other family member mentioned above was granted appointment on compassionate grounds. Date: Signature of S&WI: Name: 1. PARTICULARS OF THE DECEASED EMPLOYEE: aName of the deceased employeebDesignation/Station/DepartmentcCommunitydDate of BirtheDate of AppointmentfDate of DeathgAge at the time of demisehCause of demise 2.FAMILY COMPOSITION AND DETAILS OF OCCUPATION: Sl. No.Name S/Shri/Smt/Ms.RelationshipAge at the time of eventDate of BirthOccupationRemarks1234567 3. DETAILS OF CLAIM FOR APPOINTMENT ON COMPASSIONATE GROUND: a) In case widow apply for appointment for herself immediately after the event. Please furnish the following details. i)Name of the applicant ii)Date of application (Application to be attached)iii)Date of Birth iv) Educational Qualification (Proof to be attached) v)If illiterate, Original sworn affidavit should be produced Date: Signature of S&WI: Name: ..2.. B (i)Applicant Name  (ii)Date of Birth  (iii)Educational qualification/ Technical qualification (Proof to be attached) (iv) Is willingness taken from elder sons/elder daughters obtained and attached (should be attached in case the appointment is sought for wards other than first Son/Daughter)  (v)Is Bread Winners Certificate obtained from candidate& attached C. If the request is for eldest ward who is minor, the following details to be furnished: i)Applicant Name ii)Date of first application for appointment in his/her favour iii)Date of Birth iv) Date of attaining majorityv)Date of application submitted after obtaining majority of the first child  Signature of the applicant Signature of the Widow. :3: I. Particulars of all dependent family members of the Railway Servant (if some are employed, their income and whether they are living together or separately) Sl. No.Name S/Shir.Relation ship with the deceasedAgeAddressEmployment details of employed123456      II DECLARATION / UNDERTAKING 1. I hereby declare that the facts given by me above are, to the best of my knowledge, correct. If any of the facts herein mentioned are found to be incorrect or false at a future date, my services may be terminated. 2. I hereby also declare that I shall maintain properly the other family members who have been dependent (details given) on Railway servant mentioned against Para I of this letter and in the case it is proved at any time that the said family member are being neglected or not being properly maintained by me, further during the period of their dependency my appointment may be terminated. Dated: Signature: Name: Address: I have verified that the facts mentioned above named candidate and are found correct. I hereby certify that the candidate is residing with other dependent family members of the deceased Railway employee. Signature of the Welfare Inspector Name : Designation : and Station PROFORMA FOR FURNISHING S&WIs REPORT IN RESPECT OF COMPASSIONATE APPOINTMENT CASES I) Details of the ex-employee: 1Name 2Date of Birth 3Date of Appointment 4Community 5Date of Death 6 Post & Grade held at the Time of death/medical unfitness 7Nature of Death(a) Arising out of Railway accident in the course of employment(b) Arising out of railway/other accidents while of duty.(c ) Due to natural causes 8Date of medical decategorisation/ total unfitness(a) Medical certificate No.& date (b) Date of termination of service (Copy of O.O. to be enclosed) II) Details of the family members of the Ex-Employee: Sl. No.NameRelationshipAge/DOBEdul.QlfnMartial StatusEmployment particularsNote: Indicate how many children were actually dependent on the deceased/medically decategorised / totally incapacitated employee. 2 : 2 : II (a) (b) Are there other any claimants for Appointment other than members included in the FCC (i.e.) another widow, children of the deceased wife etc.Whether details of the family members given above tally with FCC furnished for settlement purposes, if not variation to be explained  III) Details of settlement dues/pension: P.F.Rs.DCRGRs.GISRs.SSSRs.Leave SalaryRs.Compensation under WCA (wherever Applicable)Rs.Pension:-EFP :-OFP Rs. Rs. IV) Details of the candidate in whose favour CGA is sought for:- 1Name 2D.O.B. 3Educational Qualification 4Community 5Date of application of the Ex-employee/widow for CGA6Reasons for belated submission of application ..3.. : 3 : V Present financial position of the family ( indicating movable/immovable property and the details of any other source of income, duly obtaining a declaration to this effect. VI. (a) Genuineness of the claim for CGA by the widow/candidate. (Enquiry to be made from the neighbors and report to be enclosed) (b)Genuineness of educational certificates (Genuineness to be verified from the concerned educational institution duly obtaining a letter to this effect from the Principal/Headmaster Copy to be enclosed) VII) In cases of appointment to the dependents of employees dying as bachelors/spinstersr:- 1Whether the candidate was shown as dependant in the family composition for availing passes 2Whether the deceased employee was shown as Head of the family in the Ration card 3Whether the candidates name finds a place in the Ration Card4Whether the parents of the deceased employee are alive and if so, the details of their income5Dependency of the candidate on his deceased brother/sister ( A detailed report to be given by investigating the circumstances). Date: Signature of S&WI: Name: ...4 : 4 : VIII.) In cases of Appointment to the spouse/wards of missing employees:- 1Date from the which the employee has been missing 2Whether an FIR has been filed by the family. If so, date of FIR (Copy to be enclosed) 3Whether the missing employee was declared as Not traceable. If so, date of report. (Copy to be enclosed)4Whether the genuineness of FIR and Not Traceable Report has been verified from the concerned Police Station.5 (a)Whether the missing employee was taken up under DAR for unauthorized absence. (b) If so, whether he has imposed with the penalty of removal (copy of penalty Advice to be enclosed)  (c) If so, whether the penalty of removal was annulled by the Competent Authority on receipt of FIR and Not Traceable Report. (Copy of annulment order to be enclosed). IX. In cases of Appointment to married daughters:- a)Physical fitness of the widow to take up job for herself b)Reasons for the widows inability to take up job for herself, if any c)Whether a declaration has been obtained from the married daughter to the effect that she would look after the widow and her family after appointment Date: Signature of S&WI: Name: 5 : 5 : IX. In cases of Appointment to Adopted Children:- d)Whether the ex-employee was married or a bachelor e)If married, whether he has a son/daughter apart from the adopted son. f)Whether there is an Adoption Deed, if so, whether it has been registered (date of Adoption Deed and Date of registration should be indicated duly enclosing copy of the Adoption Deed)g)Whether the ex-employee has informed the Administration that he has adopted the Son/Daughter has been included in the family composition for availing passesh)Whether the candidate (i.e.) Adopted Son/Daughter has indicated his/her Adoptive fathers name in the School/Community certificates. <> <> <> Date: Signature of S&WI Name: Particulars pertaining to the Ward/Widow/Dependent applied for appointment on Compassionate Grounds 1Name 2Deceased Employees Name and Designation3Relationship to the deceased4Age and Date of Birth5Identification Marks1. 2.6Educational/Tech. Qualification at the time of - Submission of CGA application / attaining majority7Whether group of post applied for GroupC or GroupD8Community and Caste9Present postal address 10Phone No: Signature of the Applicant Witness: Designation: 1 ... 2 ... 3 ------------------------------------------------------------------------------------------------------------------ IDENTIFICATION CERTIFICATE This is to certify that S/Shri/Kum. Son/Daughter/Wife of (late)S/Shri Residence of .. is known to me. He/She has applied for appointment on compassionate grounds in Gr.C/D post in Southern Railway. The photo affixed by the party duly attested by me. His specimen signature was obtained before me. 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