TREASURIESACCOUNTSDEPARTMENT

ANDHRAPRADEH::HYDERABAD

ApplicationForPensioner's(Service/Family)MultipurposeI.DCard
PART-I(ApplicantDetails)
1 / EmployeeCodeifavailablebeforeretirement
2 / PensionerI.D. No*
3 / NameoftheTreasury/PPOfrom wherepensionisbeingdrawn*
4 / PensionersNameSurname Fathers name/Husbandname
5 / DateofBirth(dd/mm/yyyy)*
6 / DateofdeathofservicePensionerIncaseofFamilyPensioner*
7 / DateofRetirementofServicePensioner*
8 / DateofCommencementofpension(Sp/Fp)*
9 / Retirementtype(SeeOverleaf)*
10 / TypeofFamilypension(SeeOverleaf)*
11 / NameoftheDepartmentfromWhere ServicePensionerRetired*
12 / DesignationatthetimeofretirementofServicePensioner*
13 / Designationgrade(SeeOverleaf)*
14 / Gender(M/F)*
15 / Maritalstatus(SeeOverleaf)*
16 / BloodGroup(Overleaf)
17 / Ailmentsifany(SeeOverleaf)
18 / PensionerCategory(SeeOverleaf)
19 / PensionerEmploymentCategory
(SeeOverleaf)
20 / P.R.C.Year*
21 / PresentBasicpension*
22 / PAN.NO
23 / RationCardNo
24 / AdharCardNo
25 / PresentResidentialAddresswithPincode*
26 / ResidentialPhoneNo
27 / CellNO
28 / E-MailAddress
PART-IIDEPENDENTDETAILS(IncaseofServicePensioneronly)
S.No
(1) / DependentName* (2) / Gender*(M/F) (3) / Dateofbirth*(dd/mm/yyyy)(4) / MaritalStatus (SeeOverleaf)* (5) / Relationship withPensioner(SeeOverleaf)*(6) / Employmentstatus* (7) / BloodGroup(8)

DeclarationByThePensioner(OnlyIncaseofServicePensioner)

I______doherebyConfirmthat,thelistofmyfamilymembersmentionedaboveiscompleteandtheyarefullydependentonme.Ialsodeclarethat,theinformationaboveistrue.Ialsodeclarethat,ifmydeclarationisfoundtobefalseatalatterdate,Imaybeheldresponsibleforthelapseasperrules.

SignatureoftheServicePensioner/FamilyPensioner.

Emp.Code______(ifavailable)

PensionerI.D.No______

(ForTreasuryOfficeruseonly)

(Ifrejected,SpecifyReasons)

CounterSignatureoftheTreasuryOfficer

AuthoritywithOfficeSeal

* IncaseofPensioner'sdrawingmorethanonepensionneedtoapplyforservicepensiononly.

**Incaseofemployment,noneedtoapplyunderthisschemebytheFamilyPensioner.

Part-1(Overleaf)

Sl.noDescriptions

09.Service-Normal/Service-Provisional/Service-Voluntary/Service-Invalid/Service-Prorata.

10.Family-Normal/Family-Share/Family-Minor/Family-Pcmr/DirectFamily.

13.Gazetted/Non-Gazetted/Class-IV.

15.Married/Unmarried/Widowed/Divorced/Remarried.

16.A+ve,A-ve,B+ve,B-ve,AB+ve,AB-ve,O+veandO-ve.

17.B.P/Sugar/CardiacProblems/NeurologicalProblems/KidneyProblems/Others.

18.Civil/AST/FA/Political/Others

19. StateNormal/UGC/AIS/Judicialofficer/UGC-Doctors/AICTC/OtherStates/Others

Part-II(Overleaf)

Sl.noDescriptions

5.Married/Unmarried/Widowed/Divorced/Remarried

6.Father,Mother,Spouse,SonIncludingAdoptedstepsons,DaughterincludingstepDaughter.