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SBF-FORMS FORM No. SUBJECT 1 FORM FOR SCHOLARSHIPS FOR THE YEAR 20___-20____ FOR HIGHER TECHNICAL/ PROFESSIONAL EDUCATION FOR WARDS (MALE/ GIRL) 2 MERGED WITH FORM NO.1 3 MERGED WITH FORM NO.1 4 APPLICATION FOR RESERVATION OF ACCOMMODATIONIN HOLIDAY HOME 5 APPLICATION FORM FOR MAINTENANCE ALLOWANCES 6 Application form For Relief of Distress, Serious Sickness(For cancer/kidney/AIDS/Bypass surgery/TB /Paralysis/Other serious sickness) 7 Application form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing occupational skill 8 Application form - financial assistance For Artificial Limb 9 Male employee (For Erstwhile Group 'C'& ‘D’ Staff) /Children(boys & girls)/All women employees Camp) 10 APPLICATION FOR ACCOMMODATION IN CONVALESCENT HOME AT BANDRA PALI HILL 11 Application for Immediate Relief in Times of Crises Arising Out Of Natural Calamities 12 Application form - financial assistance For DENTURE 13 Application form - financial assistance to family of Missing employees 14 Application form - financial assistance For Family Planning operation on girl child only 15 Application form - financial assistance For Amputation 16 Application form - financial assistance For Chronically ill patients requiring use of Diaper 17 Application form for Hostel Grant to Girl child for higher education 18 Application form for Financial Assistance for Adoption of orphan girl child

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Page 1: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

SBF-FORMSFORM

No. SUBJECT

1 FORM FOR SCHOLARSHIPS FOR THE YEAR 20___-20____ FOR HIGHER TECHNICAL/ PROFESSIONAL EDUCATION FOR WARDS (MALE/ GIRL)

2 MERGED WITH FORM NO.1

3 MERGED WITH FORM NO.1

4 APPLICATION FOR RESERVATION OF ACCOMMODATIONIN HOLIDAY HOME 5 APPLICATION FORM FOR MAINTENANCE ALLOWANCES

6 Application form For Relief of Distress, Serious Sickness(For cancer/kidney/AIDS/Bypass surgery/TB /Paralysis/Other serious sickness)

7 Application form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing occupational skill

8 Application form - financial assistance For Artificial Limb

9 Male employee (For Erstwhile Group 'C'& ‘D’ Staff) /Children(boys & girls)/All women employees Camp)

10 APPLICATION FOR ACCOMMODATION IN CONVALESCENT HOME AT BANDRA PALI HILL

11 Application for Immediate Relief in Times of Crises Arising Out Of Natural Calamities12 Application form - financial assistance For DENTURE 13 Application form - financial assistance to family of Missing employees 14 Application form - financial assistance For Family Planning operation on girl child only 15 Application form - financial assistance For Amputation 16 Application form - financial assistance For Chronically ill patients requiring use of Diaper 17 Application form for Hostel Grant to Girl child for higher education 18 Application form for Financial Assistance for Adoption of orphan girl child

SBF-Form No.-1 STAFF BENEFIT FUND

Page 2: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

APPLICATION FORM - SCHOLARSHIPS FOR THE YEAR 20___- 20____ FOR HIGHER TECHNICAL/PROFESSIONAL EDUCATION FOR WARDS (MALE /GIRL) OF STAFF IN GP. ABOVE RS. 2400/- AND UP TO RS.4200 /-

Section A - 1) Name of the employee ---------------------------------------------------------------------------------------------------------- (in BLOCK LETTERS) 2) Designation ---------------------------------------- PF No ------------------------------------------------------------------------ 3) Department----------------------------------------- Station of working------------------------------------------------------- 4) Working under----------------------------------------Pay bill -------------------------------- Unit No------------------------- 5) Pay sheet preparing Unit---------------------------------------------------------------------------------------------------------- 6) Name of Division/Unit/ PU------------------------------------------------------------------------------------------------------- 7) Pay band-------------------------------------------------- Grade Pay-------------------------------------------------------------- 8) Whether placed higher grade Pay under MACP Scheme, Yes/No 9) If yes, w.e.f.-------------------------10) Whether belongs to SC/ST/OBC/GEN/-------------------------------------------

Section B-(Detailed particulars in whose favour application is made)

1) Name of the Girl/Male child-------------------------------------------------------------------------------------------------- (in BLOCK LETTERS)

2) Name of college/Institute where admitted-------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ 3) Total duration of course--------------------------Years----------------------------Semesters------------------------------4) Name of the course--------------------------------------------------------------------------------------------------------------5) Stage of study during 20___-20____------------------------------------------------------------------------------------------------6) Name of Technical Degree/Diploma certificate awarded on completion of course by University----------------------------------------------------------------------------------------------------------------------------7) Whether it is Degree/Post graduate/Diploma Course--------------------------------------------------------------------8) Whether admitted in Railway subsidized hostel---------------------------------------------------------------------------9) If yes the name of the hostel---------------------------------------------------------------------------------------------------10) Name of College/Institute attended last year----------------------------------------------------------------------------11) Name of last exam passed----------------------------------------------------------------------------------------------------12) Total marks obtained -------------------------------------------Out of------------------------------------------------------ (In case of Semester system, please mention marks of each semester separately)13) Percentage of marks-----------------------------------------------------------------------------------------------------------14) Whether result declared passed in all Semester/Annual Exam. ---------------------------------------------------

Note i) Copy of passing mark sheet attested by School/College authority or Gazatted Officer. ii) In the event of ward being given scholarship; full messing charges are liable to be recovered by the

Railways.iii) Have you applied for scholarship or Merit scholarship for this student from

College/State/WRWSSCiv) If the candidate already getting scholarship from any other source, if so give

full details mentioning the amount of scholarship per annum----------------- v) If the scholarship is sanctioned by WRWWSSC then remit the scholarship received by SBF to RSBF

Head No 00812104--------------------

Contd.2/-

- 2 -

Page 3: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

In case of Semester system, please mention marks of each semester separately or otherwise final marks to be indicated

Certified that the information given by me is correct. In the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the scholarship if sanctioned& received.ENCL: 1) Attested copy of Passing mark sheet of last exam passed. (Both the Semesters/annual mark sheets whichever is applicable).2) Attested Xerox copy of latest Pay Slip for Pay Band reference. Auto phone No----------

Sign/thumb impression of employee Sign of forwarding In-charge

Name

(Thumb impression to be attested by Designation Forwarding in charge with name designation Date& Seal& seal)NOTE: It is certified that all above particulars of the employee are verified by me & found correct &

employee has attached all required documents as per check list.

Signature of dealing SBF Clerk/ Inspector. Signature of concern Personnel OfficerName Name

Designation Designation

Division/Unit Division/Units

Date Date

Office seal

Annexure “A”

Page 4: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

FOR TECHNICAL/PROFESSIONAL EDUCATION ONLY

FORM TO BE CERTIFIED BY HEAD OF INSTITUTION/COLLEGE FOR CLAIMING SCHOLARSHIP FOR GIRL/MALE CHILD OF WESTERN RAILWAY EMPLOYEES(Note—Alteration in the proforma will lead to rejection)

Certified that Miss/Master-----------------------------------------daughter/son of Shri/Smt-------------------------------------------------------------------------------------- is bonafied student of this collage/institute and the examinations are conducted by the University/Board of---------------------------------------------------

This is full time course and not part time or correspondence course.

Other particulars of course

Name of course in full---------------------------------------------------------------------------------

Date of admission----------------------------------------------------------

Stage of study for the year 20___-20____ -------------------------------------------------------

Academic session for the year 20___-20____ starts from-----------------------to--------------------

Whether availing free Scholarship from any other sources-------------------------------------

Whether in receipt of Scholarship/Stipend or any other monetary benefit from collage/institute------------------------------------------------------

If so, then amount received per annum------------------------------------------------

It is certified that all above particulars of above girl/male student are verified by collage Authorities and found correct.

Signature of the Head of Institute/Collage

Name----------------------------------------

Designation---------------------------------DatePlaceSeal

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.4 SBF Form No.-4

Page 5: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

œ¸¢©¸Ÿ¸ £½¥¸¨¸½ WESTERN� RAILWAY

Ÿ¸º‰¡¸¸¥¸¡¸ ˆÅ¸¡¸¸Ä¥¸¡¸, ¸¸ÄŠ¸½’,� �

Ÿ¸ºŸ¤¸ƒÄ-400020Headquarters office, Churchgate, Mumbai-

400 020._______________ˆ½Å ‚¨¸ˆÅ¸©¸ Š¸¼í ( í¸½¥¸ú ”½ í¸½Ÿ¸) ˆÅ½ ‚¸£®¸µ¸ ˆÅ½ ¢¥¸‡ ‚¸¨¸½™›¸

œ¸°¸ APPLICATION FOR RESERVATION OF ACCOMMODATIONIN HOLIDAY HOME AT

_______________01. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Name of employee�

______________________________________________________02. œ¸™›¸¸Ÿ¸ DesignationÀ__________________________________________________________________03. ˆÅ¸¡¸Ä ¬˜¸¥¸, ¢¨¸ž¸¸Š¸, ¬’½©¸›¸ Place of Work, Deptt. SectionÀ______________________________________04. ¬¸º¢¨¸š¸¸ ¸¸¢í‡ Accommodation Required ˆÅ¤¸ ¬¸½ from __________ˆÅ¤¸ ÷¸ˆÅ to� _______¢™›¸ Days ( ______ )05 ¡¸¢™ „œ¸£¸½ Æ÷¸ ¢™›¸¸¿ˆÅ ˆÅú ‚›¸¿ºœ¸¥¸¤‹¸÷¸¸ ˆÅú ¢¬˜¸¢÷¸ Ÿ¸½¿ ‚½¨¸¸ú/‚›¡¸�

¢™›¸¸¿ˆÅ State alternate dates in case accommodation is not available for the dates applied for: ˆÅ¤¸ ¬¸½ From: _________ ˆÅ¤¸ ÷¸ˆÅ to ________

06. i) Æ¡¸¸ ˆÅŸ¸Ä¸¸£ú ¬¸½¨¸¸ Ÿ¸½ í¾ ¡¸¸ ¬¸½¨¸¸ ¢›¸¨¸¼÷¸ Whether employee is serving� or retired _____________________

ii) ¡¸¢™ ¬¸½¨¸¸ ¢›¸¨¸¼÷¸ í¾ ÷¸¸½ ¬¸½¨¸¸¢›¸¨¸¼¢÷¸ ˆÅú ¢™›¸¸¿ˆÅ ‡¨¸¿ ‚›¡¸ ¢¨¸¨¸£µ¸ If retired, indicate the date of retirement and other particulars ________________________________________________________________

07. œ¸»¨¸Ä Ÿ¸½¿ „œ¸£¸½Æ÷¸ í¸½¥¸ú ”½ í¸½Ÿ¸ ˆÅú ¬¸º¢¨¸š¸¸ ¥¸ú í¾ , ¡¸¢™ í¸Â, ÷¸¸½ ¨¸«¸Ä ¤¸÷¸¸¡¸½ State if accommodation in the above holiday home was availed previously, if ‘Yes’ state year__________________________________________

08. ¢›¸¡¸º¢Æ÷¸ ¢™›¸¸¿ˆÅ Date of appointment: ________________¸›Ÿ¸ ¢÷¸¢˜¸ date of birth� ___________________10. Æ¡¸¸ „œ¸£¸½Æ÷¸ ‚¨¸¢š¸ ˆÅú ŽºØú ¬¨¸ úˆ¼Å÷¸ í¾ Whether leave is sanctioned for the above period : í¸Â / ›¸íú yes/No11. Ÿ¸ÿ œÏŸ¸¸¢µ¸÷¸ ˆÅ£÷¸¸ íÁ» ¢ˆÅ, Ÿ¸ÿ ˆÅ¸½ƒÄ ¸½œ¸ú £¸½Š¸ ¬¸½ ŠÏ¢¬¸÷¸ ›¸íú í»Â I�

hereby certify that I am not suffering from any contagious infectious diseases ________________________________________________________

12. ‹¸£ ˆÅ¸ œ¸÷¸¸ Home Address: __________________________________________________________

________________________________________________________________________________13. ¬¸¿œ¸ˆÄÅ ¬¸¿. Contact Number: £½¥¸¨¸½ Rly. Auto :___ ______(Ÿ¸¸½¤¸¸ƒÄ¥¸ Mobile)_____________ __________14. œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ‚¿÷¸Š¸Ä÷¸ œ¸¢£¨¸¸£ /‚¸¢ª÷¸ ˆÅú ¬¸¿‰¡¸¸ No. of Family Members/Dependents as per Pass Rule ______

¢™›¸¸¿ˆÅ Date À ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£

Signature of the applicant ˆÅ¸½ ‚ŠÏ½¢«¸÷¸ Forwarded to ____________________________,____________________________,

ˆ¼Åœ¸¡¸¸ ¤¸º¢ˆ¿ÅŠ¸ ¬¸º¢›¸¢©¸÷¸ ˆÅ£½¿ ‡¨¸¿ ¢›¸Ÿ›¸ í¬÷¸¸ ®¸£ˆÅ÷¸¸Ä ¨¸ ¬¸¿¤¸¿¢š¸÷¸� ˆÅŸ¸Ä¸¸£ú ˆ½Å œ¸÷¸½ œ¸£ ¬¸»¸›¸¸ ™½¿ —Kindly confirm booking & advise confirmation� � to undersigned & employee at his/her address.

‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£ ¨¸ œ¸™›¸¸Ÿ¸ Signature & Designation of the forwarding Officer

Page 6: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

ˆ½Å ¢¥¸‡ For _____________________________________

¬¸¿‰¡¸¸ No._____________________________¢™›¸¸¿ˆÅ Date _______________________________________ £½¥¸¨¸½ ûŸ½›¸ Rly Phone:__________________ £½¥¸¨¸½ û½ÅƬ¸ ¬¸¿. Rly Fax No._____________________________(Ÿ¸¸½¤¸¸ƒÄ¥¸ ¬¸¿‰¡¸¸ Mobile No.)______________ ™»£ž¸¸«¸ ¨¸ û½ÅƬ¸ Land line & Fax No.____________________

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.5 SBF Form No.-5 ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

STAFF BENEFIT FUNDž¸£µ¸œ¸¸½«¸µ¸ ž¸÷÷¸¸ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ œ¸°¸ Application form

For Maintenance Allowance

¸¸½ ˆÅŸ¸Ä¸¸£ú ˆ½Å £½¥¸¨¸½ ‚¸¾«¸¸š¸¸¥¸¡¸ /‚¬œ¸÷¸¸¥¸ Ÿ¸½¿ ¤¸úŸ¸¸£ú ˆ½Å ™¸¾£¸›¸ ƒ¥¸¸¸� � � ˆÅ£¸›¸½ œ¸£ ˆÅŸ¸Ä¸¸£ú ¢í÷¸›¸ú¢š¸ ¬¸½ ž¸£µ¸œ¸¸½«¸µ¸ ž¸÷÷¸¸ ¬¨¸ úˆ¼Å÷¸ ˆÅ£›¸½ ˆ½Å� ¢¥¸‡ ‚¸¨¸½™›¸ Application form for grant of Maintenance allowance from STAFF BENEFIT FUND during sickness of the employee, subject to he is taking treatment from the Railway Dispensary/Hospital. ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.-------------------Working under----------------------------------------------------Pay bill Unit No-----------------

5. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit--------------------------------------------------------

6. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit------------------------------------------------------------7. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay-----------------Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay-----------8. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¾ Whether belongs to �

SC/ST/OBC/GEN:--------------------9. ˆÅ¤¸ ¬¸½ ƒÄ¥¸¸¸ ¸¥¸ £í¸ í¾ —from treatment is going on � �

-----------------------------------------------------10.¢œ¸Ž¥¸½ ™¸¨¸¸ ˆÅ¸ ¤¡¸¸¾£¸ Details of last/past claim

---------------------------------------------------------11.¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No.£½¥¸¨¸½ Rly.:_____________(Ÿ¸¸½. M)

____________(™»£ž¸¸«¸ Land line)____________

ž¸¸Š¸ - ¤¸ Section – B ŽºØú ˆÅ¸ ¢¨¸¨¸£µ¸ LEAVE PARTICULARS :

Page 7: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ˆÅŸ¸Ä¸¸£ú ¢¤¸›¸¸ ¨¸½÷¸›¸ ŽºØú œ¸£ í¾� � This is certify that above employee is on Leave without pay ˆÅ¤¸ ¬¸½ from _________ ˆÅ¤¸ ÷¸ˆÅ To__________

¢™›¸¸¿ˆÅ Date À

ŽºØú ¢¥¸¢œ¸ˆÅ /¢¨¸ž¸¸Š¸ ׸£¸ œÏŸ¸¸¢µ¸÷¸ Certified by Clerk, Leave Section

‚¸¨¸½™ˆÅ ˆÅ¸ ˆÅ¸¡¸Ÿ¸ú œ¸÷÷¸¸ Permanent address of Applicant :___________________________________________________________________________________________________________________________________¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.:_____________ (Ÿ¸¸½. M) _____________(™»£ž¸¸«¸ Land line)_____________

________________________________________________ ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£ ¡¸¸ ‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸ Signature or thumb impression of the applicant

¬’½©¸›¸ Station:____________¢™›¸¸¿ˆÅ Date: ____________

ž¸¸Š¸ - ˆÅ Section – C (ˆ½Å¨¸¥¸ ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ž¸£¸ ¸¸‡ To be filled in by� � Railway Doctor only )

1. ¤¸úŸ¸¸£ú ˆÅ¸ œÏˆÅ¸£ Nature of illness _________________________________________________________

2. ‚¬œ¸÷¸¸¥¸ Ÿ¸½¿ ž¸÷¸úÄ / £½¥¸¨¸½ ¬¸½ £½ûÅ£¥¸ ‚¬œ¸÷¸¸¥¸ Ÿ¸½¿ ž¸½¸›¸½ ˆÅú �/£½¥¸¨¸½ ‚¸¾«¸¸š¸¥¸¡¸ Ÿ¸½¿ ƒ¥¸¸¸ ©¸º² í¸½›¸½ ˆÅú ÷¸¸£ú‰¸ Admitted to Rly. �Hospital/recommended by Rly. to referral Hospital/dispensary treatment start Dated_________

3. ‚¬œ¸÷¸¸¥¸ ¬¸½ ŽºØú /£½ûÅ£¥¸ ‚¬œ¸÷¸¸¥¸ ¬¸½ ŽºØú /£½¥¸¨¸½ ‚¸¾«¸¸š¸¥¸¡¸ Ÿ¸½¿ ƒ¥¸¸¸ œ¸»µ¸Ä í¸½›¸½ ˆÅú ÷¸¸£ú‰¸ Discharged from Railway Hospital/referral �Hospital dated ____________________ ¡¸¸ ƒ¥¸¸¸ ¸¸¥¸» í¾ or treatment continue.� �

4. £½¥¸¨¸½ ‚¸¾«¸¸š¸¥¸¡¸ /‚¬œ¸÷¸¸¥¸ Ÿ¸½¿ í¸¸£ú ™ú Attended at the Rly. Hospital �/Dispensary ˆÅ¤¸ ¬¸½ from __________ ˆÅ¤¸ ÷¸ˆÅ to_____________________________

5. £½¥¸¨¸½ ‚¸¾«¸¸š¸¥¸¡¸ /‚¬œ¸÷¸¸¥¸ ˆ½Å ¢¸¢ˆÅ÷¬¸ˆÅ ›¸½ ¬¨¸¬˜¸÷¸¸ œÏŸ¸¸µ¸œ¸°¸ �¸¸£ú ¢ˆÅ¡¸¸ Declared fit to report for duty by the Doctor, Hospital/Dispensary on �¢™›¸¸¿ˆÅ dated ________________

›¸¸½’ NOTE:- œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ „œ¸£¸½Æ÷¸ ¢¨¸¨¸£µ¸ ¬¨¸¬˜¸÷¸¸� œÏŸ¸¸µ¸œ¸°¸ ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾ —Certified that the above facts are true and are according to sick & fit Certificate.

¡¸¢™ Ÿ¸£ú¸ ˆÅú ¤¸úŸ¸¸£ú ˆÅ¸ œÏˆÅ¸£ ‡½¬¸¸ í¸½ ¢ˆÅ „¬¸½ £½¥¸¨¸½ ‚¬œ¸÷¸¸¥¸ ˆ½Å� ‚¥¸¸¨¸¸ £½ûÅ£¥¸ ‚¬œ¸÷¸¸¥¸ Ÿ¸½¿ ž¸½¸›¸¸ ¸²£ú í¾ ÷¸¸½ ¢›¸Ÿ›¸ œÏŸ¸¸µ¸œ¸°¸ £½¥¸¨¸½ ¢¸� � �¢ˆÅ÷¬¸ˆÅ ׸£¸ ¢™¡¸¸ ¸¸‡ In case where the disease is of such a nature where the patient� has/had to be admitted in a Hospital, other than Railway, the following certificate is required to be filled in by the Medical Officer.

Page 8: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ Ÿ¸£ú¸ ˆÅ¸½ ™½¡¸ ¢¸¢ˆÅ÷¬¸¸ ¬¸º¢¨¸š¸¸ £½¥¸¨¸½� � � ‚¸¾«¸¸š¸¥¸¡¸ /‚¬œ¸÷¸¸¥¸ Ÿ¸½¿ „œ¸¥¸¤š¸ ›¸íú í¾ Certified that the medical treatment as required by the patient is not available in a Railway Hospital or Dispensary.(œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ Ÿ¸£ú¸ ¢¤¸›¸¸ ¨¸½÷¸›¸ ŽºØú ˆ½Å ™¸¾£¸›¸ £½¥¸¨¸½ ¢¸� � �¢ˆÅ÷¬¸ˆÅ ˆ½Å ‚š¸ú›¸ ƒ¥¸¸¸ Ÿ¸½¿ í¾ / ˜¸¸ It is certified that patient is/was under Railway� Doctor’s treatment between LWP)›¸¸½’ NOTE: ¸¸½ ¥¸¸Š¸» ›¸ í¸½ „¬¸½ ˆÅ¸’½¿ Strike off whichever is not applicable.�

¢™›¸¸¿ˆÅ Date À _____________________________________________________

¢¸¢ˆÅ÷¬¸¸¸ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£ ¨¸ Ÿ¸¸½í£� Signature & Seal of Medical Officer

ž¸¸Š¸ - ” Section – D ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£ Signature & Seal of forwarding officer

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ˆ½Å Å¢›¸¡¸Ÿ¸¸½ ˆ½Å ‚›¸º¬¸¸£ ™¸¨¸¸ ¬¸íú í¾ /¬¸íú ›¸íú í¾ Claim is� correct / in correct as per SBF terms & condition.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢¥¸¢œ¸ˆÅ Dealing clerk SBF �

™¸¨¸¸ Claim of ` ____________/- ˆÅ¸ ¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ / ‚¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ is approved / Rejected.

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

¨¸½÷¸›¸ ‚¸™½©¸ ¬¸¿‰¡¸¸ Pay order No. _____________________________________ ¢™›¸¸¿ˆÅ dated _______________

ˆÅ¸½ ¸¸£ú ¢ˆÅ¡¸¸ issued to� __________________________________________________________________.

<><><><>

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.6 SBF Form No.-6 ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

STAFF BENEFIT FUNDˆÅ¢“›¸¸ƒÄ Ÿ¸½ £¸í÷¸, Š¸¿ž¸ú£ ¤¸úŸ¸¸£ú Ÿ¸½¿ Ÿ¸™™ˆ½Å ¢¥¸‡

‚¸¨¸½™›¸ œ¸°¸ Application form For Relief of Distress, Serious Sickness

(ˆ½Å›¬¸£/ˆÅú”›¸ú/‡”¬¸Ã /¤¸¸¡¸œ¸¸¬¸ /’ú¤¸ú / ¥¸ˆÅ¨¸¸ / Š¸¿ž¸ú£ ¤¸úŸ¸¸£ú ˆ½Å ¢¥¸‡ )

(For cancer/kidney/AIDS/Bypass surgery/TB /Paralysis/Other serious sickness)ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ �

À-------------------------------------------------------------------------------------

Page 9: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

2. Name of the employee (in BLOCK LETTERS) -----------------------------------------------------

3. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

4. Designation -----------------------------------------------PF/PRAN No --------------------------5. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------6. Department--------------------------------------------Station of working--------------------------7. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸

¡¸»¢›¸’ ¬¸¿.------------------8. Working under----------------------------------------------------Pay bill Unit No----------------9. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing

Unit-------------------------------------------------------10. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of

Division/Unit-----------------------------------------------------------11. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay-----------------Ÿ¸»¥¸

¨¸½÷¸›¸ Basic Pay----------12. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¾ Whether belongs �

to SC/ST/OBC/GEN:---------------------13. ¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.:____________ (Ÿ¸¸½. M)

____________(™»£ž¸¸«¸ Land line)___________

ž¸¸Š¸ - ¤¸ Section – B Ÿ¸£ú¸ ˆÅ¸ ¢¨¸¨¸£µ¸ Details of patient:� 1) Ÿ¸£ú¸ ˆÅ¸ ›¸¸Ÿ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ Name of Patient for whom � �

assistance is sought--------------------------------------------------------------------------------------------------------------------

2) ˆÅŸ¸Ä¸¸£ú ˆ½Å ¬¸¸˜¸ ¬¸¿¤¸¿š¸ Relationship with the �employee-----------------------------------------------

3) Æ¡¸¸ Ÿ¸£ú¸ Ä œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ¬¸½ ©¸¢¬¸÷¸ í¾ ? If dependant is covered under� pass rule? ---------------------------

4) £¸½Š¸ ˆÅ¸ œÏˆÅ¸£ Name of disease--------------------------------------------------------------------

5) ƒÄ¥¸¸¸ ˆÅ¸ ¬˜¸¸›¸ Place of �treatment-----------------------------------------------------------------

6) Æ¡¸¸ ¢ûÅ¥¸í¸¥¸ ƒÄ¥¸¸¸ ¸¥¸ £í¸ í¾ Whether still undergoing � �treatment-------------------------------------

7) Æ¡¸¸ ˆÅ.¢í.›¸ú. ¬¸½ œÏ˜¸Ÿ¸¤¸¸£ ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ ¢ˆÅ¡¸¸ í¾ Whether applying for financial assistance for first time from SBF------------------------------

8) ¡¸¢™ ›¸¸, ÷¸¸½ œ¸»¨¸Ä Ÿ¸½¿ œÏ¸œ÷¸ £¸¢©¸ ˆÅ¸ ¤¡¸¸¾£¸ If not, then details of amount received in past ----------------------

(ˆ¼Åœ¸¡¸¸ ¸¸¥¸» Ÿ¸¸¬¸ ˆÅú œ¸½ ¬¥¸úœ¸ ¨¸ ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ / � �™¬÷¸¸¨¸½¸ ¬¸¿¥¸Š›¸ ˆÅ£½¿ � Kindly enclosed current pay slip & doctor's certificate / documents)

‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾, ¢ûÅ£ ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ� ¸¸÷¸ú í¾ ÷¸¸½ ‚›¸º©¸¸¬¸›¸ ¨¸ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸� £í¿ºÁŠ¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received.

¢™›¸¸¿ˆÅ Date ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£ �Signature of employees

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ž¸¸Š¸ - ˆÅ Section – C £½¥¸¨¸½ / ¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸� � Recommendation of Railway/ Non Railway Doctor :

£¸½Š¸ ˆÅ¸ œÏˆÅ¸£ Name of disease--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- £¸½Š¸ ˆÅ¸ ¬¸¿¿¢®¸œ÷¸ Ÿ¸½¿ ¢¨¸¨¸£µ¸ Brief details of disease:-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

£½¥¸¨¸½ / ¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ¨¸ Ÿ¸¸½í£ � � Signature of Railway /non Railway doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal ¢™›¸¸¿ˆÅ Date :

ž¸¸Š¸ - ” - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – D - for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation--------------- ¢™›¸¸¿ˆÅ Date

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Ÿ¸¸½í£ Seal

2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Forwarding official to Headquarter:œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸¸ � � � �Š¸¡¸¸ í¾ ‡¨¸¿ ¬¸íú í¾ — ¡¸í ™¸¨¸¸ œÏ˜¸Ÿ¸¤¸¸£ íú ¢ˆÅ¡¸¸ ¸¸ £í¸ í¾ —� Certified that all above particulars/ entries have been checked thoroughly and found correct & He / she has claimed amount first time

ˆÅŸ¸Ä¸¸£ú £¸¢©¸ � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ —

Employee is eligible for amount ` -------------.

œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸¢š¸ ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢«¸÷¸ �¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ � ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal ¢™›¸¸¿ˆÅ Date:

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.7 SBF Form No.-7 ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

STAFF BENEFIT FUND‚œ¸¿Š¸/Ÿ¸¿™¤¸º¢šš¸ ˆ½Å ‚¸¢ª÷¸ ˆÅ¸½ ¢¨¸©¸½«¸ ÷¸¸¾£ œ¸£ £

¥¸ˆÅŸ¸úÄ ˆ½Å ¥¸”ˆÅú ˆÅ¸½ ¨¡¸¸¨¸¬¸¸¢¡¸ˆÅ ˆºÅ©¸¥¸÷¸¸ ¤¸õ¸›¸½ ˆ½Å ¢¥¸‡ ‚¸¢˜¸ÄˆÅ Ÿ¸™™ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸�

œ¸°¸ ¨¸«¸Ä 20___-20 ___.Application form For Financial Assistance to Physically/Mentally

challenged wards especially Girl of Railway employee for Training for

developing Occupational skill -Year 20___-20 ___.

ž¸¸Š¸ -ˆÅ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.------------------

5. Working under----------------------------------------------------Pay bill Unit No----------------6. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing

Unit-------------------------------------------------------7. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit-----------------------------------------------------------8. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------9. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:---------------------ž¸¸Š¸ - ‰¸ Section – B ‚¸¢ª÷¸ ˆ Ÿ ¢¨¸¨¸£µ¸ Details of dependent: 1. ‚¸¢ª÷¸ ˆÅ¸ ›¸¸Ÿ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ Name of dependent for whom �

assistance is sought-----------------------------------------------------------------------------------------------------------------------

2. ˆÅŸ¸Ä¸¸£ú ˆ½Å ¬¸¸˜¸ ¬¸¿¤¸¿š¸ Relationship with the �employee---------------------------------------------------

3. Æ¡¸¸ Ÿ¸£ú¸ œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ¬¸½ ©¸¢¬¸÷¸ í¾ ? If dependant is covered under pass rule? �-------------------------------

4. £¸½Š¸ ˆÅ¸ œÏˆÅ¸£ Name of disease------------------------------------------------------------------------5. Ÿ¸¸›¡¸ ¬¸¿¬˜¸¸›¸ ˆÅ¸ ›¸¸Ÿ¸ ¸í¸Â ¬¸½ œÏŸ¸¸µ¸œ¸°¸ í¸¢¬¸¥¸ ¢ˆÅ¡¸¸ í¸½ Name of �

authorized institution From which certificate is obtained------------------------------------------------------------------------------------------

6. ‚¸¢ª÷¸ ‚œ¸¿Š¸ í¾ ¡¸¸ Ÿ¸¿™¤¸º¢šš¸ ˆÅ¸ Dependant is physically handicapped or mentally challenged---------------

7. ‚œ¸¿Š¸÷¸¸ ˆ½Å Handicapped %--------------- Ÿ¸¿™¤¸º¢šš¸ ˆ½Å ¤¸¸¾¢ÖˆÅ ¬÷¸£ Mentally retarded IQ % ----------------

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8. ˆÅ.¢í.¢›¸. ¬¸½ œÏ˜¸Ÿ¸¤¸¸£ ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ ¢ˆÅ¡¸¸ í¾ Whether applying for financial assistance for first time from SBF------------------------------

9. ¡¸¢™ ›¸¸, ÷¸¸½ Š¸÷¸ œÏ¸œ÷¸ £¸©¸ú ˆÅ¸ ¤¡¸¸¾£¸ If not, then details of amount received in past ------------------------------------------------------------------------------------------------------------------------------

¬¸¿¥¸Š›¸ Encl: 1. Ÿ¸¸›¡¸ ¬¸£ˆÅ¸£ú œÏŸ¸¸µ¸œ¸°¸ ˆÅú œÏ¢÷¸ Attested Copies of certificates of Authorized Govt. Institution. 2. ¨¡¸¸¨¸¬¸¸¢¡¸ˆÅ ˆºÅ©¸¥¸÷¸¸ ¤¸¸›¸½¨¸¸¥¸ú ¡¸¸ ¬ˆ»Å¥¸ ˆÅ¸� œÏŸ¸¸µ¸ œ¸°¸ Certificate of occupation developing institutes / school.

¬˜¸¸›¸ Place:¢™›¸¸¿ˆÅ Date:

ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£ �Signature of employees

ž¸¸Š¸ - Š¸ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C - for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation--------------- ¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal 2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Forwarding official to Headquarter:œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ — ¡¸í ™¸¨¸¸ ¬ˆ»Å¥¸ú ¤¸¸½ ˆÅ¸½ ‡ˆÅ¤¸¸£ ž¸ú ›¸íú ¢™¡¸¸ Š¸¡¸¸ í¾�� ‡¨¸¿ ¨¡¸¨¸¬¸¸¢¡¸ˆÅ ˆºÅ©¸¥¸÷¸¸ ¤¸¸›¸½ ˆÅú ¢¨¸©¸½«¸ ¬ˆ»Å¥¸ /¬¸¿¬˜¸¸ Ÿ¸½¿ ¸¸ £í¸ í¾� � ÷¸¸½ œÏŸ¸¸µ¸œ¸°¸ ¬¸¿¥¸Š›¸ ˆÅ£½¿ — Certified that all above particulars/ entries have been checked

thoroughly and found correct & It has been verified from this office record that above named employee has not obtained one time payment from SBF his/her son/daughter is not going special school and attached all necessary documents.

ˆÅŸ¸Ä¸¸£ú £¸¢©¸ � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ — Employee is eligible for amount ` -------------.œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸¢š¸ ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢«¸÷¸ �¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

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ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½�¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal ¢™›¸¸¿ˆÅ Date:

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‚›¸º¤¸¿š¸ “ ‚ ” Annexure “A”œ¸¢©¸Ÿ¸ £½¥¸¨¸½ ˆ½Å ‚œ¸¿Š¸/Ÿ¸¿™¤¸º¢šš¸ ˆ½Å ‚¸¢ª÷¸ ˆÅ¸½ ¨¡¸¨¸¬¸¸¢¡¸ˆÅ�

ˆºÅ©¸¥¸÷¸¸ ¤¸õ¸›¸½ ˆ½Å œÏ¢©¸®¸µ¸ ™½›¸½¨¸¸¥¸ú ¬¸¿¬˜¸¸ ׸£¸ ¢™¡¸½� ¸¸›¸½¨¸¸¥¸½ ¢¨¸¨¸£µ¸ ˆÅ¸ ›¸Ÿ¸»›¸¸ �

Particulars to be furnished by Institution where physically / mentally challenged ward of Western Railway employee is undergoing training:-

¤¸¸½ /‚¸¢ª÷¸ ˆÅ¸ ›¸¸Ÿ¸ Name of child/Dependent ��_____________________________________________

1. ¢œ¸÷¸¸ ˆÅ¸ ›¸¸Ÿ¸ ¨¸ „œ¸›¸¸Ÿ¸ Father‘s Name & Surname :___________________________________________

2. ¨¡¸¨¸¬¸¸¢¡¸ˆÅ ˆºÅ©¸¥¸÷¸¸ ¤¸¸›¸½¨¸¸¥¸½ ¬¸¿¬˜¸¸ ˆÅ¸ ›¸¸Ÿ¸ ¸í¸Â � � ‚œ¸¿Š¸ /Ÿ¸¿™¤¸º¢šš¸ ˆ½Å ‚¸¢ª÷¸ œÏ¢©¸®¸µ¸ ¥¸½ £í¸ í¾ — Name of Occupational training Centre in which the Physically /Mentally challenged ward is undergoing training :__________________________________________________________________________

3. œ¸¸“á¸ÇÅŸ¸ ˆÅ¸ ›¸¸Ÿ¸ Name of course :_______________________________________________________

4. ©¸¾®¸¢µ¸ˆÅ ¬¸°¸ ˆÅú ‚¨¸¢š¸ Duration of course academic ¨¸«¸Ä year : 20________- 20 __________ˆÅ¤¸ ¬¸½ From_________________________ ˆÅ¤¸ ÷¸ˆÅ To __________________

5. œ¸¸“á¸ÇÅŸ¸ ˆ½Å ‚¿÷¸ Ÿ¸½¿ ¸¸£ú í¸½›¸½¨¸¸¥¸½ œÏŸ¸¸µ¸œ¸°¸ ˆÅ¸ ›¸¸Ÿ¸ Name of �certificate awarded at the end : ____________ ________________________________________________________________________________

6. Æ¡¸¸ ¤¸¸¸ /‚¸¢ª÷¸ ¢›¸¡¸¢Ÿ¸÷¸ ¬ˆ»Å¥¸ ¸¸ £í¸ í¾ — Whether the child / dependent is �� �attending school regularly regularly: í¸Â / ›¸íú Yes / NO

7. ˆ¡¸¸ ¤¸¸¸ /‚¸¢ª÷¸ ˆÅ¸½ƒÄ ¢©¸«¡¸¨¸¼¢÷¸ ¥¸½ £í½ í¾ Whether any stipend is being ��paid to the ward : ___________ ________________________________________________________________________________¡¸¢™ í¸Á , ÷¸¸½ ¢ˆÅ÷¸›¸¸ ? if yes, Then how much? ` ________________

¬¸¿¬˜¸¸ ˆÅú Ÿ¸¸½í£ Seal of Institute ¬¸¿¬˜¸¸ ˆ½Å œÏŸ¸º‰¸ ˆÅ½ í¬÷¸¸®¸£ Signature of Head of Institute¬¸¿¬˜¸¸ ˆ½Å œÏŸ¸º‰¸ ˆÅ¸ ›¸¸Ÿ¸ Name of head of institute-----------------------------------------------------œ¸™›¸¸Ÿ¸ Designation À ¬˜¸¸›¸ Place: ¢™›¸¸¿ˆÅ Date:

„œ¸ Ÿ¸º‰¡¸ ¢¸¢ˆÅ÷¬¸¸ ‚¢š¸ˆÅ¸£ú (÷¸.¨¸ œÏ.)-¸¸ÄŠ¸½’ ׸£¸ œÏŸ¸¸¢µ¸÷¸ Certified by� � � Dy. CMD (T&A) -CCG :

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

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‚›¸º¤¸¿š¸ “ ¤¸ ” Annexure “B”£½¥¸ ˆÅŸ¸Ä¸¸£ú ׸£¸ ¸¸£ú ‚œ¸¿Š¸/Ÿ¸¿™¤¸º¢šš¸ ˆ½Å ‚¸¢ª÷¸ ˆÅ¸ ¢¸¢¨¸÷¸ œÏŸ¸¸µ¸œ¸°¸ � � �

Live certificate of Handicapped challenged/Mentally Retarded ward from Railway Employee

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, � It is certified that ªú / shri ____________________________________ œ¸º°¸ / œ¸º°¸ú Son/daughter ____________________________________ Ÿ¸½£¸ ‚œ¸¿Š¸/Ÿ¸¿™¤¸º¢šš¸ ˆÅ¸ ‚¸¢ª÷¸ í¾ ‡¨¸¿ ¨¸í ¢¨¸©½¸«¸ / ¢›¸¡¸¢Ÿ¸÷¸ ¬ˆ»Å¥¸ ›¸íú ¸¸ £í¸ í¾ ‡¨¸¿ Ÿ¸½£½ ¬¸¸˜¸ £í £í¸ í¾� ‡¨¸¿ œ¸»µ¸Ä÷¸¡¸¸ Ÿ¸º¸ œ¸£ ‚¸¢ª÷¸ í¾ is handicapped/physically challenged� /Mentally retarded ward of undersigned & not going in any special school, regular school & residing with me & totally dependent on me. ¡¸í ‚¸¸ ÷¸ˆÅ ¢¸¢¨¸÷¸ í¾� � He/She is alive as on date.

ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£ Signature of employees�™¸½ ¬¸¸®¸ú ˆÅ¸ ¢¨¸¨¸£µ¸ ‡¨¸¿ í¬÷¸¸®¸£ :1. ¬¸¸®¸ú ˆÅ½ í¬÷¸¸®¸£ Signature of witnessÀ ______________________________________________________

¬¸¸®¸ú ˆÅ¸ ›¸¸Ÿ¸ Name of witnessÀ ____________________________________________________________ ¬¸¸®¸ú ˆÅ¸ œ¸™›¸¸Ÿ¸ Designation of witnessÀ _____________________________________________________ œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿. PF/PRAN No À _____________________________________________________________ ˆÅ¸¡¸Ä ¬˜¸¥¸ Work place: ____________________________________________________________________ ˆÅ¸¡¸¸Ä¥¸¡¸ Office : _________________________________________________________________________2. . ¬¸¸®¸ú ˆÅ½ í¬÷¸¸®¸£ Signature of witnessÀ ______________________________________________________

¬¸¸®¸ú ˆÅ¸ ›¸¸Ÿ¸ Name of witnessÀ ____________________________________________________________ ¬¸¸®¸ú ˆÅ¸ œ¸™›¸¸Ÿ¸ Designation of witnessÀ _____________________________________________________ œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿. PF/PRAN No À _____________________________________________________________ ˆÅ¸¡¸Ä ¬˜¸¥¸ Work place: ____________________________________________________________________ ˆÅ¸¡¸¸Ä¥¸¡¸ Office : _________________________________________________________________________

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.8 SBF Form No.-8 ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

STAFF BENEFIT FUNDˆ¼Å¢°¸Ÿ¸ ‚¨¸¡¸¨¸ í½÷¸» ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ œ¸°¸

(ŠÏ½” œ¸½ ` 1800/- ¨¸ ¡¸¸™¸ ˆ½Å ¢¥¸‡)� Application form - financial assistance For Artificial Limb from SBF for GP

Rs.1800/- and Above ( œ¸»¨¸ÄˆÅ¸¥¸ ˆ½Å ¨¸Š¸Ä ‘š¸’ ˆÅŸ¸Ä¸¸£ú ˆ½Å ¢¥¸‡ - ¸¸í½ „¸ ŠÏ½”� � ��

œ¸½ ‡Ÿ¸‡¬¸úœ¸ú Ÿ¸½¿ ¢™¡¸¸ Š¸¡¸¸ í¸½ ) (For Erstwhile Group ‘D’ Staff only- even higher GP issued in

MACPS)ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.------------------Working under----------------------------------------------------Pay bill Unit No----------------

5. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit-------------------------------------------------------

6. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit-----------------------------------------------------------7. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------8. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:---------------------

ž¸¸Š¸ - ¤¸ Section – B ¢¨¸¨¸£µ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ details for which � assistance saught:

01.ˆÅŸ¸Ä¸¸£ú ¬¨¸¿¡¸¿ ˆÅ¸ /‚¸¢ª÷¸ / ¤¸¸½ ›¸¸Ÿ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ Name of � �� �self /ward/dependant for whom assistance is sought:-----------------------------------------------------------------------------------------

02.ˆÅŸ¸Ä¸¸£ú ˆ½Å ¬¸¸˜¸ ¬¸¿¤¸¿š¸ Relationship with the �employee---------------------------------------------------

03.Æ¡¸¸ Ÿ¸£ú¸ œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ¬¸½ ©¸¢¬¸÷¸ í¾ ? If dependant is covered under pass rule? �---------------------------------

04.¢¨¸Ž½™ ˆÅ¸ œÏˆÅ¸£ Type of amputation:------------------------------------------------------------------�05.ƒ¥¸¸¸ ˆÅ¸ ¬˜¸¸›¸ Place of treatment:--------------------------------------------------------------------�06.Æ¡¸¸ ¢ûÅ¥¸í¸¥¸ ƒ¥¸¸¸ ¸¥¸ £í¸ í¾ Whether still undergoing � �

treatment:----------------------------------------07.Æ¡¸¸ ˆÅ.¢í.¢›¸. ¬¸½ œ¸»¨¸Ä Ÿ¸½ Ÿ¸™™ ¢Ÿ¸¥¸ú í¾ Whether any assistance sought from

SBF earlier ( ¡¸¢™ í¸Â, ˆ¼Åœ¸¡¸¸ ¢¨¸¨¸£µ¸ ¢™¢¸‡ If yes, details �pl) :---------------------------------------------------------------------------------

08.‚œ¸¿Š¸÷¸¸ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ ˆÅú ¬¸÷¡¸¸¢œ¸÷¸ œÏ¢÷¸ Attested copy of disability certificate attached (í¸Â / ›¸íú Yes / NO)

09.Æ¡¸¸ ‚¨¸¡¸¨¸ ©¸£ú£ ˆ½Å ›¸ú¸½ ˆ½Å ¢í¬¬¸½ ¬¸½ í¾ Whether the artificial limp is for �lower part (í¸Â / ›¸íú Yes / NO)

10.ˆ¿Åœ¸›¸ú ˆÅ¸ Ÿ¸»¥¸ ¸¸¥¸¸›¸ ¬¸¿¥¸Š›¸ í¾ Original invoice from company enclosed (í¸Â / �›¸íú Yes / NO)

11.ˆÅ¼¢°¸Ÿ¸ ‚¨¸¡¸¨¸ ˆÅú ¥¸¸Š¸÷¸ Cost of Artificial Limp: `-------------------------------------------------------

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(ˆ¼Åœ¸¡¸¸ ¸¸¥¸» Ÿ¸¸í ˆÅú œ¸½ ¬¥¸úœ¸ ¨¸ ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ / ™¬÷¸¸¨¸½¸� � � ¬¸¿¥¸Š›¸ ˆÅ£½¿ Kindly enclosed current pay slip & doctor's certificate / documents)

‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾, ¢ûÅ£ ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½� � ‚›¸º©¸¸¬¸›¸ ¨¸ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸ £í¿ºÁŠ¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received.

¬¸¿¥¸Š›¸ Encl: 1. Ÿ¸¸›¡¸ ¬¸£ˆÅ¸£ú ¬¸¿¬˜¸¸ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ ˆÅú œÏ¢÷¸ Attested Copies of certificates of Authorized Govt. Institution. 2. ˆ¿Åœ¸›¸ú ˆÅ¸ Ÿ¸»¥¸ ¸¸¥¸¸›¸� Original invoice from company.

¬˜¸¸›¸ Place:¢™›¸¸¿ˆÅ Date:

ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£� Signature of employees

ž¸¸Š¸ - ˆÅ Section – C £½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸� Recommendation of Railway Doctor :

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ „œ¸£¸½Æ÷¸ ™©¸¸¡¸½Ä ¨¡¸¢ˆÅ÷¸ ˆÅ½ ©¸£ú£ ˆ½Å �›¸ú¸½ ˆ½Å ¢í¬¬¸½ ˆÅ¸ ‚¨¸¡¸¨¸ ˆÅ¸ ¢¨¸Ž½™ ¢ˆÅ¡¸¸ Š¸¡¸¸ í¾ It is certified that the above � �person had amputated the Lower Limp as mentioned above.

£½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ˆ½Å í¬÷¸¸®¸£ �¨¸ Ÿ¸¸½í£ Signature of Railway doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal

¢™›¸¸¿ˆÅ Date***

¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸ ¡¸¢™ í¸½ ÷¸¸½ Recommendation of � �NON Railway Doctor (If any)

¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ � �ˆ½Å í¬÷¸¸®¸£ ¨¸ Ÿ¸¸½í£ Signature of private doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :

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ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal ¢™›¸¸¿ˆÅ Date

ž¸¸Š¸ - ” - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – D- for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal

2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Forwarding official to Headquarter:œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ —Certified that all above particulars/ entries have been checked thoroughly and found correct.

ˆÅŸ¸Ä¸¸£ú £¸¢©¸ � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ — ƒ¬¸ ¬¨¸úˆ¼Å÷¸ í¸½›¸½¨¸¸¥¸ú £¸¢©¸ ˆÅ¸½ ˆ¼Å¢°¸Ÿ¸ ‚¨¸¡¸¨¸ ¤¸›¸¸›¸½¨¸¸¥¸ú ˆ¿Åœ¸›¸ú ¢¸¬¸ˆÅ¸ ¸¸¥¸¸›¸ ‚¸¨¸½™›¸ ˆ½Å ¬¸¸˜¸ � �¬¸¿¥¸Š›¸ ¢ˆÅ¡¸¸ í¾ „¬¸½ ¸½¿ˆÅ ¬¸½ ž¸ºŠ¸÷¸¸›¸ ˆÅú ¢¬¸ûŸ¢£©¸ ˆÅú ¸¸÷¸ú í¾ —� �Employee is eligible for amount ` -------------. It is recommended that, payment to be made through cheque to company whose quotation enclosed with application.

œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸¢š¸ ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢«¸÷¸ �¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½�¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal ¢™›¸¸¿ˆÅ Date:

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ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

<<<>>>

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.9 SBF Form No.-9 ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ - œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

- STAFF BENEFIT FUNDœ¸º²«¸ ˆÅŸ¸Ä¸¸£ú ŠÏ½” œ¸½ 1900 ¨¸ ‚¢š¸ˆÅ (œ¸»¨¸ÄˆÅ¸¥¸ ˆ½Å ¨¸Š¸Ä � ‘ˆÅ’ ˆÅŸ¸Ä¸¸£ú�

ˆ½Å ¢¥¸‡) / œ¸º²«¸ ˆÅŸ¸Ä¸¸£ú ŠÏ½” œ¸½ 1800 ¨¸ ˆÅŸ¸ (œ¸»¨¸ÄˆÅ¸¥¸ ˆ½Å ¨¸Š¸Ä � ‘š¸’ ˆÅŸ¸Ä¸¸£ú�

ˆ½Å ¢¥¸‡ -¸¸í½ „¸ ŠÏ½” œ¸½ ‡Ÿ¸‡¬¸úœ¸ú Ÿ¸½¿ ¢™¡¸¸ Š¸¡¸¸ í¸½) / � ��¤¸¸¸½ (¥¸”ˆ½Å ¨¸ ¥¸”ˆÅú) / ÷¸Ÿ¸¸Ÿ¸ Ÿ¸¢í¥¸¸ ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢©¸¢¨¸£ �� �

Male employee GP 1900 & more (For Erstwhile Group ‘C’ Staff only / Male employee GP 1800 & less (For Erstwhile Group ‘D’ Staff only- even higher GP

issued in MACPS)/ children(boys & girls)/All women employee’s Camp

‚¸¨¸½™›¸ œÏ¬÷¸º÷¸ ˆÅ£›¸½ ˆÅú ‚¿¢÷¸Ÿ¸ ¢÷¸¢˜¸ --------------- (ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸� ¢›¸£ú®¸ˆÅ /¢¥¸¢œ¸ˆÅ ׸£¸ ž¸£¸ /ˆÅ¸’¸ /‚¿¢ˆÅ÷¸ ¢ˆÅ¡¸¸ ¸¸‡)�

Last date for submission of application is ---------------(To be filled up /strike out/ tick mark by SBF clerk/Inspector)

ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.------------------

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Working under----------------------------------------------------Pay bill Unit No----------------5. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing

Unit-------------------------------------------------------6. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit-----------------------------------------------------------7. œ¸½ ¤¸½¿›” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay-----------------Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------8. Ÿ¸¸ƒÄ¥¸½¸ ž¸÷÷¸¸ Mileage Allowance -----------------------(£›¸ìŠ¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å œÏˆÅ£µ¸ � �

Ÿ¸½ For running Allowance)9. ¸›Ÿ¸ ¢™›¸¸¿ˆÅ Date of Birth ------------------------¢›¸¡¸º¢ˆ÷¸ ¢™›¸¸¿ˆÅ Date of �

Appointment-------------------10.¬¸½¨¸¸ ¢›¸¨¸¼¢÷¸ ¢™›¸¸¿ˆÅ Date of superannuation

------------------------------------------------------------11.Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:---------------------12.¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.:____________ (Ÿ¸¸½. M)

____________(™»£ž¸¸«¸ Land line)___________13.‹¸£ ˆÅ¸ œ¸÷¸¸ Home Address: __________________________________________________________: ž¸¸Š¸ - ¤¸ Section – B ¢©¸¢¨¸£ ¬¸¿¤¸¿š¸ú ¢¨¸¨¸£µ¸ Camp details: 1. ¬¨¸¸¬˜¸ ˆÅ¸ ¬¸¸Ÿ¸¸›¡¸ ¢¨¸¨¸£µ¸ Particulars of general health ( ¬¨¸¡¸¿ ˆÅú ¬¨¸¸¬˜¸ ˆÅú

‹¸¸½«¸µ¸¸ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ ¬Ï¥¸¿Š›¸ ¢ˆÅ¡¸¸ í¾ ¡¸¢™ ¸¡¸›¸ íº‚¸ ÷¸¸½ self declaration of �health certificate to be attached , if selected ) Yes /No

2. Æ¡¸¸ ˆÅŸ¸Ä¸¸¢£ ›¸½ œ¸í¥¸½ ˆ½Å.ˆÅ.¢í.¢›¸.-œ¸.£½. ׸£¸ ‚¸¡¸¸½¢¸÷¸ ¢©¸¢¨¸£ � �Ÿ¸½¿ ¢í¬¬¸¸ ¢¥¸¡¸¸ í¾ Whether the employee has ever attended camp organized by CSBF W. Rly Yes /No

3. ¢©¸¢¨¸£ £¸¢©¸ Camp Fee : ` ---------------------‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸¸½«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾, ‡¨¸¿ ¢©¸¢¨¸£ ˆ½Å ™¸¾£¸›¸ ‚›¸º©¸¸¬¸›¸ ¤¸›¸¸¡¸½ £�‰¸º¿Š¸¸ Š¸¥¸÷¸ œ¸¸¡¸½ ¸¸›¸½ œ¸£ ‚›¸º©¸¸¬¸›¸ ‡¨¸¿ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸ ˆÅ¸¡¸Ä¨¸¸íú ˆÅú� ¸¸ ¬¸ˆÅ÷¸ú í¾ � — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action..

¢™›¸¸¿ˆÅ Date ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£ /‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸� Sign of the employee / thumb impression ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C - for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal 2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Forwarding official to Headquarter:œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ — ¡¸í ˆÅŸ¸Ä¸¸¢£ ›¸½ œ¸í¥¸½ ˆ½Å.ˆÅ.¢í.¢›¸.-œ¸.£½. ׸£¸ ‚¸¡¸¸½¢¸÷¸� � ¢©¸¢¨¸£ Ÿ¸½¿ ¢í¬¬¸¸ ¢¥¸¡¸¸ ›¸íú ¢¥¸¡¸¸ í¾ — ¡¸¢™ ˆÅŸ¸Ä¸¸£ú ›¸½ œ¸í¥¸½ ˆ½Å.ˆÅ.¢í.¢›¸.-�œ¸.£½. ׸£¸ ‚¸¡¸¸½¢¸÷¸ ¢©¸¢¨¸£ Ÿ¸½¿ ¢í¬¬¸¸ ¢¥¸¡¸¸ œ¸¸¡¸¸ Š¸¡¸¸ ÷¸¸½ „¢¸÷¸ ˆÅ¸¡¸Ä¨¸¸íú� � ˆÅú ¸¸¡¸½Š¸ú — � Certified that all above particulars/ entries have been checked thoroughly and found correct & Certified that the above mentioned employee had not attended camp before. In case it is proved that if he/she has attended, action may be taken accordingly.

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ˆÅŸ¸Ä¸¸£ú ׸£¸ œ¸¸°¸ ™½¡¸ £¸¢©¸ ‚š¡¸¸™½©¸¸›¸º¬¸¸£ � ` -------------------- Amount to be paid by employee as per notification ` -------------.œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸¢š¸ ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢«¸÷¸ �¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½�¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal ¢™›¸¸¿ˆÅ Date:

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ - œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY - STAFF BENEFIT FUND

¢©¸¢¨¸£ Ÿ¸½¿ ©¸¸¢Ÿ¸¥¸ í¸½›¸½ˆÅ¸½ ¬¨¸¸¬˜¸ ¬¸¿¤¸¿š¸ú ¬¨¸¡¸¿ ˆÅú ‹¸¸½«¸µ¸¸

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SELF-HEALTH DECLARATION FOR ATTENDING CAMP

Ÿ¸ÿ ¢›¸Ÿ›¸ í¬÷¸¸®¸£ˆÅ÷¸¸Ä ‹¸¸½«¸µ¸¸ ˆÅ£÷¸¸/ˆÅ£÷¸ú íÁ» ¢ˆÅ, I the undersigned hereby declare that,

1. Ÿ¸ÿ ¢ˆÅ¬¸ú ‚¬¸¸‹¡¸, ¬œ¸©¸Ä ¬¸½ û½Å¥¸›¸½¨¸¸¥¸½ ¡¸¸ ¬¸¿ÇŸŸ¸ˆÅ / ¸½œ¸ú £¸½Š¸ ¬¸½ ŠÏ¢¬¸÷¸ ›¸íú í»Â — I am not� suffering from any serious, contagious & infectious diseases.

2. Ÿ¸ÿ ¢©¸¢¨¸£ ˆ½Å ™¸¾£¸›¸ ¬¸úöú ‡¨¸¿ ¸¸ƒÄ /œ¸í¸” ¸›¸½ ¬¸®¸Ÿ¸� � � � � í» — I am able to climb stairs & hills during camp.

3. Ÿ¸º¸½ ¢©¸¢¨¸£ /¡¸¸°¸¸ ˆ½Å ™¸¾£¸›¸ ¢ˆÅ¬¸ú ¬¸í¸£ ¡¸¸ ¢¨¸©¸½«¸� � ¬¸í¸¡¸÷¸¸ ˆÅú ‚¸¨¸©¡¸Æ÷¸¸ ›¸íú í¾ — I need not require companion or special assistance during camp & journey.

4. Ÿ¸ÿ ‚œ¸¿Š¸ ˆÅŸ¸Ä¸¸£ú í» ‡¨¸¿ Ÿ¸ÿ Ÿ¸½£¸ ¢›¸¡¸¢Ÿ¸÷¸ ¢ÇÅ¡¸¸ÇÅŸ¸� ˆÅ£ ¬¸ˆÅ÷¸¸ í» ‡¨¸¿ Ÿ¸½£½ ¢¥¸‡ ¢¨¸©¸½«¸ ¬¸í¸¡¸÷¸¸ ˆÅú ‚¸¨¸©¡¸Æ÷¸¸ ›¸íú í¾ — (ˆÅ½¨¸¥¸ ‚œ¸¿Š¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å ¢¥¸‡� ‚›¡¸˜¸¸ ˆÅ¸’ ™½ ) I am handicapped employee & can perform my routine activities and no special assistance is required for me.(Applicable to handicapped employees only other wise strike)

5. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Ÿ¸ÿ ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¬¸½ ‚¸¡¸¸½¢¸÷¸ ¢©¸¢¨¸£ /¡¸¸°¸¸ ˆÅ£›¸½� � Ÿ¸¸›¸¢¬¸ˆÅ ‡¨¸¿ ©¸¸£ú¢£ˆÅ ÷¸¸¾£ œ¸£ ¬¨¸¬˜¸ í» ‡¨¸¿ ¢ˆÅ¬¸ú ¬¸í¸£, ¡¸¸÷¸¸¡¸¸÷¸ ¡¸¸ ¢¨¸©¸½«¸ ¬¸í¸¡¸÷¸¸ ˆÅú Ÿ¸¸¿Š¸ ›¸íú ˆÅ²¿Š¸¸ —�¿ I am physically and mentally fit to undertake journey as well as camp organised by CSBF. I will not ask any special escort / assistance / transport for undersigned.

¢©¸¢¨¸£¸˜¸úÄ ˆ½Å í¬÷¸¸®¸£ Signature of Camper ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£ Signature of employee�(ˆ½Å¨¸¥¸ ¤¸¸¸½ ˆ½Å ¢¥¸‡ For children camp) (÷¸Ÿ¸¸Ÿ¸�� ¢©¸¢¨¸£ ˆ½Å ¢¥¸‡ For all the camps)›¸¸Ÿ¸ Name:------------------- ›¸¸Ÿ¸ Name: ------------------------------------ œ¸™›¸¸Ÿ¸ Designation: -----------------------------¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No:---------------- (ˆÅŸ¸Ä¸¸£ú� Employee)----------------------------

(‹¸£ /‚¸œ¸¸÷¸ˆÅ¸¥¸ú›¸ ¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Resi/Emergency contact No)------------------- ----------- ¢™›¸¸¿ˆÅ Date:

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.10 SBF Form No.-10

œ¸¢©¸Ÿ¸ £½¥¸¨¸½ WESTERN� RAILWAY

Ÿ¸º‰¡¸¸¥¸¡¸ ˆÅ¸¡¸¸Ä¥¸¡¸, ¸¸ÄŠ¸½’,� �

Ÿ¸ºŸ¤¸ƒÄ-400020Headquarters office, Churchgate, Mumbai-

400 020.œ¸¸¥¸úíú¥¸ - ¤¸¸¿Í¸ ˆ½Å œ¸º›¸À¬¨¸¸¬˜¸¥¸¸ž¸¸½›Ÿ¸º‰¸ Š¸¼í ˆÅ½ ‚¸£®¸µ¸ ˆÅ½ ¢¥¸‡

‚¸¨¸½™›¸ (ˆ½Å¨¸¥¸ ¨¸Š¸Ä ‘ ̂ Å ’ (¡¸¸›¸ú œ¸º¨¸Ä¨¸÷¸ ¨¸Š¸Ä ‘ ̂ Å ’ ¨¸ ˆ½Å ‘ š¸ ’ ÷¸Ÿ¸¸Ÿ¸) ˆÅŸ¸Ä¸¸£ú /�

¬¸½¨¸¸ ¢›¸¨¸¼÷¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å ¢¥¸‡)�APPLICATION FOR ACCOMMODATION IN CONVALESCENT HOME AT BANDRA PALI

HILL(For all Group ‘C’ staff / retired staff (erstwhile Group ‘C’ & ‘D’ staff) only)

ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details: � 01. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Name of employee ----------------------------------------------------------------�

¬¸¿œ¸ˆÄÅ ¬¸¿. Contact Number: £½¥¸¨¸½ Rly. Auto ---- --------(Ÿ¸¸½¤¸¸ƒÄ¥¸ Mobile)----------------------------02. œ¸™›¸¸Ÿ¸ DesignationÀ------------------------------------------------------------------------------03. ˆÅ¸¡¸Ä ¬˜¸¥¸, ¢¨¸ž¸¸Š¸, ¬’½©¸›¸ Place of Work, Deptt.

SectionÀ----------------------------------------------04. ¬¸º¢¨¸š¸¸ ¸¸¢í‡ Accommodation Required ˆÅ¤¸¬¸½ from --------------ˆÅ¤¸ ÷¸ˆÅ to� ----------¢™›¸ Days (----)05 ¡¸¢™ „œ¸£¸½ˆÅ÷¸ ¢™›¸¸¿ˆÅ ˆÅú ‚›¸ºœ¸¥¸¤‹¸÷¸¸ ˆÅú ¢¬˜¸¢÷¸ Ÿ¸½¿ ‚½¨¸¸ú�

¢™›¸¸¿ˆÅ State alternate dates in case accommodation is not available for the dates applied for: ˆÅ¤¸ ¬¸½ From: ------------------- ˆÅ¤¸ ÷¸ˆÅ to ------------------

06. i) Æ¡¸¸ ˆÅŸ¸Ä¸¸£ú ¬¸½¨¸¸ Ÿ¸½ í¾ ¡¸¸ ¬¸½¨¸¸ ¢›¸¨¸¼÷¸ í¾ Whether employee is� serving or retired ------------------------

ii) ¡¸¢™ ¬¸½¨¸¸ ¢›¸¨¸¼÷¸ í¾ ÷¸¸½ ¬¸½¨¸¸¢›¸¨¸¼¢÷¸ ¢™›¸¸¿ˆÅ ‡¨¸¿ ‚›¡¸ ¢¨¸¨¸£µ¸ If retired, indicate the date of retirement and other particulars ----------------------------------------------------------------------------------

07. ˆÅ¸£µ¸À£½¥¸¨¸½ ¢¨¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ‘í¨¸¸ û½Å£’ ˆÅ¸ ¬¸º¸¸¨¸ PurposeÀfor � ‘Change of Air’ recommended by railway doctor for ¬¨¸¿Ÿ¸ self / œ¸¢÷›¸ wife / œ¸º°¸ son / œ¸º°¸ú daughter /‚¸¢ª÷¸ dependent ˆ½Å ¢¥¸‡ ----------------------------

08. ¬¸¿¥¸Š›¸ À ¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œÏŸ¸¸µ¸ œ¸°¸ ¢¸¬¸Ÿ¸½¿ � � � ‘í¨¸¸ û½Å£’ ˆÅ¸ ¬¸º¸¸¨¸� ¢™¡¸¸ í¸½ ‡¨¸¿ £½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ í¸½ ¡¸¸ £½¥¸¨¸½ ¢¸� �¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œÏŸ¸¸µ¸ œ¸°¸ ¢¸¬¸Ÿ¸½¿ � ‘í¨¸¸ û½Å£’ ˆÅ¸ ¬¸º¸¸¨¸ ¢™¡¸¸ í¸½ (¡¸í 15� ¢™›¸ ¬¸½ ‚¢š¸ˆÅ ›¸ í¸½›¸¸ ¸¸¢í‡ ‡¨¸¿ ¢¨¸©¸½«¸ ˆÅ¸£µ¸ Ÿ¸½¿ ‚¢š¸ˆÅ÷¸Ÿ¸ ‡ˆÅ Ÿ¸¸í� ¬¸½ ‚¢š¸ˆÅ ›¸íú í¸½›¸¸ ¸¸¢í‡) Enclosed: Private doctor� ’s certificate duly certified by Rly doctor or Rly doctor’s certificate recommended for ‘Change for Air’ . (it should not me more than 15 days & case of spl. reasons not more than one month).

09. ¢›¸¡¸º¢Æ÷¸ ¢™›¸¸¿ˆÅ Date of appointment: ------------------¸›Ÿ¸ ¢÷¸¢˜¸ date of birth� -----------------------10. œ¸¢£¸¡¸ ¢ˆÅ ¢¥¸‡ ¬¸º¢¨¸š¸¸ œ¸¸¬¸ / œ¸ú’ú‚¸½ /£½¬¸ú”½›¬¸ú¡¸¥¸ ˆÅ¸”Ä œ¸¸¬¸�

Privilege pass /PTO / residential card pass / medical pass ¬¸¿‰¡¸¸ No.-------------------ˆÅ¤¸ ¬¸½ from------------------ˆÅ¤¸ ÷¸ˆÅ to ------------------ ¸¸£ú ˆÅ÷¸¸Ä issued by� ----------------------¡¸¸ or £½¥¸¨¸½ œ¸¢£¸¡¸ œ¸°¸ ¬¸¿¥¸Š›¸ ˆÅ£½¿ railway identity card� for identification to be attached.(attached copy)

11. œ¸¢£¨¸¸£ ‡¨¸¿ ¢¤¸Ÿ¸¸£ú ˆÅ¸ ¤¡¸¸½£¸ ¢™¸ú‡ Furnish family particulars & diseases. �

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ÇÅŸ¸ ¬¸¿.Sr.No.

›¸¸Ÿ¸Name

¬¸¿¤¸¿š¸Relation

„ŸÏAge

‚¸¢ª÷¸÷¸¸Dependency

¢¤¸Ÿ¸¸£ú ¨¸ ’úœœ¸µ¸úDisease &

remark

1.2.3.4.5.6.

12. ‹¸£ ˆÅ¸ œ¸÷¸¸ Home Address: __________________________________________________________

____________________________________________¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No._________________13 œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ‚¿÷¸Š¸Ä÷¸ œ¸¢£¨¸¸£ /‚¸¢ª÷¸ ˆÅú ¬¸¿‰¡¸¸ No. of Family Members/Dependents as per Pass Rule ______

‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£ Signature of the applicant ¢™›¸¸¿ˆÅ Date:

ž¸¸Š¸ - ¤¸ Section – B £½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸� Recommendation of Railway Doctor :

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ „œ¸£¸½Æ÷¸ ™©¸¸¡¸½Ä ¨¡¸¢ˆÅ÷¸ ˆÅ½ ¢¥¸‡ � ‘í¨¸¸ û½Å£’ „›¸ˆ½Å ¬¨¸¸¬˜¸ ˆ½Å ¢¥¸‡ ¥¸¸ž¸™¸¡¸ú í¾ It is certified that the above person’s recommendation of ‘Change of Air’ is beneficial for his/her health .

£½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ˆ½Å í¬÷¸¸®¸£ �¨¸ Ÿ¸¸½í£ Signature of Railway doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal

¢™›¸¸¿ˆÅ Date:

***ˆÅ¸½ ‚ŠÏ½¢¬¸÷¸ Forwarded to ¬¸¢¸¨¸ - ˆ½Å.ˆÅ.¢í.¢›¸. Secretary - CSBF � ‡¨¸¿ &„œ¸ Ÿ¸º‰¡¸ ˆÅ¸¢Ÿ¸ÄˆÅ ‚¢š¸ˆÅ¸£ú (ˆÅ¥¡¸¸µ¸) ¸¸ÄŠ¸½’,� �Dy.CPO/W/CCG,

ˆ¼Åœ¸¡¸¸ ¤¸º¢ˆ¿ÅŠ¸ ¬¸º¢›¸¢©¸÷¸ ˆÅ£½¿ ‡¨¸¿ ¢›¸Ÿ›¸ í¬÷¸¸®¸£ˆÅ÷¸¸Ä ¨¸ ¬¸¿¤¸¿¢š¸÷¸� ˆÅŸ¸Ä¸¸£ú ˆ½Å œ¸÷¸½ œ¸£ ¬¸»¸›¸¸ ™½¨¸½¿ — Kindly confirm booking & advise� � confirmation to undersigned & employee at his/her address.

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‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å í¬÷¸¸®¸£ ¨¸ œ¸™›¸¸Ÿ¸ Signature & Designation of the forwarding Officer

ˆ½Å ¢¥¸‡ For _____________________________________

¬¸¿‰¡¸¸ No._____________________________¢™›¸¸¿ˆÅ Date _______________________________________ £½¥¸¨¸½ ûŸ½›¸ Rly Phone:__________________ £½¥¸¨¸½ û½ÅƬ¸ ¬¸¿. Rly Fax No._____________________________(Ÿ¸¸½¤¸¸ƒÄ¥¸ ¬¸¿‰¡¸¸ Mobile No.)______________ ™»£ž¸¸«¸ ¨¸ û½ÅƬ¸ Land line & Fax No.____________________

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.11 SBF Form No.-11 ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ - œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

- STAFF BENEFIT FUNDœÏ¸ˆ¼Å¢÷¸ˆÅ ‚¸œ¸™¸ ˆ½Å ¬¸Ÿ¸¡¸ „÷œ¸››¸ œ¸¢£¢¬˜¸¢÷¸ Ÿ¸½¿ ÷¸÷ˆÅ¸¥¸ £¸í÷¸ ˆ½Å

¢¥¸‡ ‚¸¨¸½™›¸Application for Immediate Relief in Times of Crises Arising Out Of Natural

Calamitiesž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.------------------Working under----------------------------------------------------Pay bill Unit No----------------

5. œ¸½ ¢¤¸¥¸ ¤¸›¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit-------------------------------------------------------

6. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit-----------------------------------------------------------7. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------8. Ÿ¸¸ƒÄ¥¸½¸ ž¸÷÷¸¸ Mileage Allowance -----------------------(£›¸ìŠ¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å œÏˆÅ£µ¸ � �

Ÿ¸½ For running Allowance)9. ¸›Ÿ¸ ¢™›¸¸¿ˆÅ Date of Birth ------------------------¢›¸¡¸º¢ˆ÷¸ ¢™›¸¸¿ˆÅ Date of �

Appointment-------------------10.¬¸½¨¸¸ ¢›¸¨¸¼¢÷¸ ¢™›¸¸¿ˆÅ Date of superannuation

------------------------------------------------------------11.Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:---------------------12.¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.:____________ (Ÿ¸¸½. M)

____________(™»£ž¸¸«¸ Land line)___________

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ž¸¸Š¸ - ¤¸ Section – B œÏ¸ˆ¼Å¢÷¸ˆÅ ‚¸œ¸™¸ ˆÅ¸ ¢¨¸¨¸£µ¸ Natural Calamity details:

01. œÏ¸ˆ¼Å¢÷¸ˆÅ ‚¸œ¸™¸ ˆÅ¸ œÏˆÅ¸£ Types of Natural Calamity:-------------------------------------------------

02. Æ¡¸¸ ˆÅŸ¸Ä¸¸£ú ¬¸£ˆÅ¸£ / £½¥¸¨¸½ / ˆ½Å.ˆÅ.¢í.¢›¸.¬¸¢Ÿ¸¢÷¸ ׸£¸ ‚¸œ¸™¸ŠÏ¬÷¸ �š¸¸½¢«¸÷¸ ®¸¿°¸ Ÿ¸½¿ £í÷¸¸ í¾ Is employee resides in notified Natural Calamity effected area by Govt./ Railway/ CSBF/ otherwise:--------------------------------------

03. Æ¡¸¸ ‚›¡¸ 縸½÷¸ ¬¸½ ‚¸¢˜¸ÄˆÅ ¬¸í¸¡¸÷¸¸ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ ¢ˆÅ¡¸¸ í¾ Whether applying for financial assistance from any other source:-----------------------------------------------------------------------------------¡¸¢™ í¸ ÷¸¸½ ¢¨¸¨¸£µ¸ ¢™¢¸‡ if yes give �details :---------------------------------------------------------------------------------------------------------------------------------------------------------

04. ‚¿™¸¢¸÷¸ ›¸ºˆÅ©¸¸›¸ Approximately loss :� -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸¸½«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾,� ¢ûÅ£ ž¸ú ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½ ‚›¸º©¸¸¬¸›¸ ¨¸ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸� ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸ £íº¿Š¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received.

ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£ /‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸ Sign of� the employee / thumb impression

¢™›¸¸¿ˆÅ Date:ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C - for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date:Ÿ¸¸½í£ Seal 2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Forwarding official to Headquarter:œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ — ¡¸í ˆÅŸ¸Ä¸¸£ú ¬¸£ˆÅ¸£ / £½¥¸¨¸½ / ˆ½Å.ˆÅ.¢í.¢›¸.¬¸¢Ÿ¸¢÷¸ ׸£¸� š¸¸½¢«¸÷¸ œÏ¸ˆ¼Å¢÷¸ˆÅ ‚¸œ¸™¸ š¸¸½¢«¸÷¸ ®¸½°¸ Ÿ¸½¿ £í÷¸¸ í¾ Certified that all above particulars/ entries have been checked thoroughly and found correct & employee is resides in notified Natural Calamity effected area by Govt./ Railway/ CSBF/ otherwise.

ˆÅŸ¸Ä¸¸£ú £¸¢©¸ � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ — Employee is eligible for amount ` -------------.œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸¢š¸ ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢«¸÷¸ �¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ —�

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Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½�¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal ¢™›¸¸¿ˆÅ Date:

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.12 SBF Form No.-12ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY STAFF BENEFIT FUND

™¸¿÷¸ ˆ½Å ¸¸½ˆÅ“½ ˆ½Å í½÷¸» ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡� ‚¸¨¸½™›¸ œ¸°¸ (÷¸Ÿ¸¸Ÿ¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å� ¢¥¸‡)

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Application form - financial assistance For DENTURE from SBF (For All employees)

ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 01. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À--------------------------------------------------------------------------------�02. Name of the employee (in BLOCK LETTERS) -------------------------------------------------03. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.------------------------

Designation -----------------------------------------------PF/PRAN No ---------------------04. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸ /¬’½©¸›¸------------------------

Department--------------------------------------------Station of working---------------------05. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.-------------

Working under----------------------------------------------------Pay bill Unit No-----------06. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit---------------------------------------------------07. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit--------------------------------------------------------08. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸ Basic Pay--------09. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:----------------10. ƒ¥¸¸¸ ˆÅ¸ ¬˜¸¸›¸ Place of treatment:----------------------------------------------------------------�11. ‚¸¿¢©¸ˆÅ /‚¸š¸¸ /œ¸»£¸ ¸¸½ˆÅ“¸ ¢¤¸“¸¡¸¸ í¾ Partial/Half/full Denture �

provided:-------------------------------12. ¸¸½ˆÅ“½ ˆÅú ¥¸¸Š¸÷¸ Cost of Denture :� `-------------------(¬¸÷¡¸¸¢œ¸÷¸ ¢¤¸¥¸

œÏ¬÷¸»÷¸ ˆÅ£½¿ Submit Attested bill)13. Ÿ¸»¥¸ ¢¤¸¥¸ ˆÅŸÏ¸¿ˆÅ Original Bill No.:---------------------------------- ¢™›¸¸¿ˆÅ

Date:------------------14. Æ¡¸¸ ˆÅ.¢í.¢›¸. ¬¸½ œ¸»¨¸Ä Ÿ¸½ Ÿ¸™™ ¢Ÿ¸¥¸ú í¾ Whether any assistance sought

from SBF earlier ( ¡¸¢™ í¸Â, ˆ¼Åœ¸¡¸¸ ¢¨¸¨¸£µ¸ ¢™¢¸‡ If yes, details �pl) :-----------------------------------------------------------------------

15. ‚¸¨¸½™ˆÅ ˆÅ¸ ˆÅ¸¡¸Ÿ¸ú œ¸÷÷¸¸ Permanent address of Applicant :______________________________________________________________________________________________________________________

16. ¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.:_____________(Ÿ¸¸½.M) __________(™»£ž¸¸«¸ Land line)___________

¬’½©¸›¸ Station:____________¢™›¸¸¿ˆÅ Date: ____________

‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾, ¢ûÅ£ ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½� � ‚›¸º©¸¸¬¸›¸ ¨¸ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸ £í¿ºÁŠ¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received.

________________________________________________ ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£ ¡¸¸ ‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸ Signature or thumb impression of the applicant

¬¸¿¥¸Š›¸ Encl: ¸¸¥¸» Ÿ¸¸í ˆÅú œ¸½ ¬¥¸úœ¸ ¨¸ ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ¢¤¸¥¸ Current pay� � slip & doctor's bill

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ž¸¸Š¸ -¤¸ Section – B £½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸� Recommendation of Railway Doctor :

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ „œ¸£¸½Æ÷¸ ™©¸¸¡¸½Ä ˆÅŸ¸Ä¸¸£ú ׸£¸ � �‚¸¿¢©¸ˆÅ /‚¸š¸¸ /œ¸»£¸ ¸¸½ˆÅ“¸� ¢¤¸“¸¡¸¸ í¾ Š¸¡¸¸ í¾

It is certified that the above employee is using Partial / Half/ full Denture.

£½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ˆ½Å í¬÷¸¸®¸£ �¨¸ Ÿ¸¸½í£ Signature of Railway doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal

¢™›¸¸¿ˆÅ Date

ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C- for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal 2. ¹¬¨¸ˆ¼Å÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å ¢¥¸‡ for Sanctioning official :œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ —‚¸¿¢©¸ˆÅ /‚¸š¸¸ / œ¸»£¸ ¸¸½ˆÅ“¸ œÏ˜¸Ÿ¸¤¸¸£ ¥¸½ £í¸ í¾ —�Certified that all above particulars/ entries have been checked thoroughly and found correct. First time Claim of Partial / Half/ full Denture.ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ˆ½Å Å¢›¸¡¸Ÿ¸¸½ ˆ½Å ‚›¸º¬¸¸£ ™¸¨¸¸ ¬¸íú í¾ /¬¸íú ›¸íú í¾ Claim is� correct / in correct as per SBF terms & condition.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢¥¸¢œ¸ˆÅ Dealing clerk SBF �

™¸¨¸¸ Claim of ` ____________/- ˆÅ¸ ¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ / ‚¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ is approved / Rejected.

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

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¨¸½÷¸›¸ ‚¸™½©¸ ¬¸¿‰¡¸¸ Pay order No. _____________________________________ ¢™›¸¸¿ˆÅ dated _______________

ˆÅ¸½ ¸¸£ú ¢ˆÅ¡¸¸ issued to� __________________________________________________________________.

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.13 SBF Form No.-13

ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY STAFF BENEFIT FUNDŠ¸ºŸ¸©¸º™¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å œ¸£ú¨¸¸£ ˆÅ¸½ ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢�

¥¸‡ ‚¸¨¸½™›¸ œ¸°¸ (÷¸Ÿ¸¸Ÿ¸ ˆÅŸ¸Ä¸¸£ú ˆ½Å� ¢¥¸‡) Application form - financial assistance to family of Missing employees from SBF

(For All employees) ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 01. ‚¸¨¸½™ˆÅ ˆÅ¸ ›¸¸Ÿ¸ À----------------------------------------------¢£¬÷¸¸ ------------------------------

Name of Applicant :---------------------------------------- Relation --------------------------02. Š¸ºŸ¸©¸º™¸ ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ �À--------------------------------------------------------------------------

Name of the missing employee (in BLOCK LETTERS) -----------------------------------------03. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.------------------------

Designation -----------------------------------------------PF/PRAN No ---------------------04. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸ /¬’½©¸›¸------------------------

Department--------------------------------------------Station of working---------------------05. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.-------------

Working under----------------------------------------------------Pay bill Unit No-----------06. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit---------------------------------------------------07. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit--------------------------------------------------------08. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸ Basic Pay--------17. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:----------------18. ‡ûÅ‚¸ƒÄ‚¸£ ˆÅ¸ ¬˜¸¸›¸ Place of FIR:----------------------------------------------------------------19. ‡ûÅ‚¸ƒÄ‚¸£ ˆÅú ¬¸¿‰¡¸¸ ‡¨¸¿ ¢™›¸¸¿ˆÅ No. & Date of FIR:---------------------------

¢™›¸¸¿ˆÅ Date:----------20. Æ¡¸¸ ˆÅ.¢í.¢›¸. ¬¸½ œ¸»¨¸Ä Ÿ¸½ Ÿ¸™™ ¢Ÿ¸¥¸ú í¾ Whether any assistance sought

from SBF earlier ( ¡¸¢™ í¸Â, ˆ¼Åœ¸¡¸¸ ¢¨¸¨¸£µ¸ ¢™¢¸‡ If yes, details �pl) :-------------------------------------------------------------------------

21. ‚¸¨¸½™ˆÅ ˆÅ¸ ˆÅ¸¡¸Ÿ¸ú œ¸÷÷¸¸ Permanent address of Applicant :______________________________________________________________________________________________________________________

22. ¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.:_____________(Ÿ¸¸½.M) __________(™»£ž¸¸«¸ Land line)___________

¬’½©¸›¸ Station:____________¢™›¸¸¿ˆÅ Date: ____________

‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾, ¢ûÅ£ ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½� � ¬¨¸úˆ¼Å÷¸ £¸¢©¸ ˆÅ¸½ ¢›¸œ¸’¸£¸ Ÿ¸ ½¬¸½ ˆÅ¸’›¸½ ‡¨¸¿ ‡¬¸¤¸ú‡ûÅ ©¸ú«¸Ä Ÿ¸½¿ œ¸º›¸À ¥¸¸½’¸›¸½ ˆÅú ¬¸íŸ¸¢÷¸ ™½÷¸¸ / ™½÷¸ú íÁ» — Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ Š¸ºŸ¸©¸º™¸ ˆÅŸ¸Ä¸¸£ú ‚¸¸ ¢™›¸¸¿ˆÅ ÷¸ˆÅ ¥¸¸œ¸÷¸¸ í¾ � � I hereby declare that, if any information &

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undertaking given is found false at any stage or subsequent stage, the grant of maintenance allowance on plea of missing employee is liable to deducted from settlement dues of missing employee & credited to SBF head . I hereby declare that “Missing employee is still missing & not traceable on day of claim”.

________________________________________________ ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£ ¡¸¸ ‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸ Signature or thumb impression of the applicant

¬¸¿¥¸Š›¸ Encl: œ¸½ ¬¥¸úœ¸ ¨¸ ‡ûÅ‚¸ƒÄ‚¸£ ˆÅú œÏ¢÷¸ Copy of pay slip & FIR

ž¸¸Š¸ -¤¸ Section – B ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ ˆÅŸ¸Ä¸¸£ú Š¸ºŸ¸©¸º™¸ í¾ „›¸ˆ½Å œ¸£ú¨¸¸£ ›¸½ � �‡ûÅ‚¸ƒÄ‚¸£ ˆÅ£¸ƒÄ í¾ ‡¨¸¿ œÏ©¸¸¬¸›¸ ˆÅ¸½ ‚¨¸Š¸÷¸ ˆÅ£¸¡¸¸ Š¸¡¸¸ í¾ It is certified that the above employee is missing & his/her family member had lodged FIR & informed to Administration. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date:Ÿ¸¸½í£ Seal

ž¸¸Š¸ -ˆÅ Section – C ¹¬¨¸ˆ¼Å÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å ¢¥¸‡ for Sanctioning official :œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ ˆÅŸ¸Ä¸¸£ú Š¸ºŸ¸©¸º™¸ í¾ „›¸ˆ½Å œ¸£ú¨¸¸£ ›¸½ � �‡ûÅ‚¸ƒÄ‚¸£ ˆÅ£¸ƒÄ í¾ ‡¨¸¿ œÏ©¸¸¬¸›¸ ˆÅ¸½ ‚¨¸Š¸÷¸ ˆÅ£¸¡¸¸ Š¸¡¸¸ í¾ It is certified that the above employee is missing & his/her family member had lodged FIR & informed to Administration.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ˆ½Å Å¢›¸¡¸Ÿ¸¸½ ˆ½Å ‚›¸º¬¸¸£ ™¸¨¸¸ ¬¸íú í¾ /¬¸íú ›¸íú í¾ Claim is� correct / in correct as per SBF terms & condition.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢¥¸¢œ¸ˆÅ Dealing clerk SBF �

™¸¨¸¸ Claim of ` ____________/- ˆÅ¸ ¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ / ‚¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ is approved / Rejected.

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

¨¸½÷¸›¸ ‚¸™½©¸ ¬¸¿‰¡¸¸ Pay order No. _____________________________________ ¢™›¸¸¿ˆÅ dated _______________

ˆÅ¸½ ¸¸£ú ¢ˆÅ¡¸¸ issued to� __________________________________________________________________.

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary

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¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.14 SBF Form No.-14 ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

STAFF BENEFIT FUNDˆ½Å¨¸¥¸ ¥¸”ˆÅú¡¸¸½¿ œ¸£ œ¸£ú¨¸¸£ ¢›¸¡¸¸½¸›¸ ˆÅ£¸›¸½ œ¸£ ˆ½Å� í½÷¸» ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ œ¸°¸ (÷¸Ÿ¸¸Ÿ¸ ˆÅŸ¸Ä¸¸£ú�

)Application form - financial assistance For Family Planning operation on girl child

only (All employees)©¸÷¸½Ä À 1. œ¸£ú¨¸¸£ ¢›¸¡¸¸½¸›¸ ¸ú¨¸ú÷¸ ™¸½ ¥¸”ˆÅú¡¸¸½ ÷¸ˆÅ ˆÅ£¸›¸½ � �œ¸£ ™½¡¸ 2. ‚¸½œ¸£½©¸›¸ ˆ½Å ¬¸Ÿ¸¡¸ ‚¸¡¸º À œ¸º³«¸ -40 ¨¸«¸Ä ¡¸¸ ˆÅŸ¸ ¨¸ Ÿ¸¢í¥¸¸-35 ¨¸«¸Ä ¡¸¸ ˆÅŸ¸ Condition: 1. Family Planning operation done on two surviving girl child only. 2. Age of at the time of operation : Male 40 years or less & For Female 35 years or less.ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 01. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À--------------------------------------------------------------------------------�02. Name of the employee (in BLOCK LETTERS) -------------------------------------------------03. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.------------------------

Designation -----------------------------------------------PF/PRAN No ---------------------04. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸ /¬’½©¸›¸------------------------

Department--------------------------------------------Station of working---------------------05. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.-------------

Working under----------------------------------------------------Pay bill Unit No-----------06. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit---------------------------------------------------

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07. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit--------------------------------------------------------08. œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸ Basic Pay--------09. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:----------------10. ¢ˆÅ÷¸›¸½ ¤¸¸½ ‚¸¸ ¸ú¢¨¸÷¸ í¾ ----------- ƒ¬¸Ÿ¸½¿ ¢ˆÅ÷¸›¸½ ¥¸”ˆ½Å í¾ ----------- �� � �

ƒ¬¸Ÿ¸½¿ ¢ˆÅ÷¸›¸ú ¥¸”¢ˆÅ¡¸¸Á í¾ ---------------No. Of children alive on date ----------- --- out of which No. Of Male children -------------- --- & No. Of Girl Children -------------- ---.

11. œÏ˜¸Ÿ¸ ¥¸”ˆÅú ˆÅ¸ ›¸¸Ÿ¸ Name of first girl child ----------- ------------ ¸›Ÿ¸ ÷¸¸£ú‰¸ Date �of Birth ---------------

12. ™º¬¸£ú ¥¸”ˆÅú ˆÅ¸ ›¸¸Ÿ¸ Name of Second girl child ----------- -------------¸›Ÿ¸ ÷¸¸£ú‰¸ �Date of Birth ---------------

13. œ¸£ú¨¸¸£ ¢›¸¡¸¸½¸›¸ ˆ½Å ‚¸½œ¸£½©¸›¸ ¢ˆÅ¬¸›¸½ ˆÅ£¸¡¸¸ Who is Operated for �Family planning À ----------- ----------

14. ¬¸¿¤¸¿š¸ Relation ----- -------------------- ‚¸½œ¸£½©¸›¸ ¢™›¸¸¿ˆÅ Date of Operation : ----- ----------------

15. ‚¬œ¸÷¸¸¥¸ ˆÅ¸ ›¸¸Ÿ¸ Name of Hospital À----- ------------------------- ------------------------- ------

16. ‚¸½œ¸£½©¸›¸ ¢™›¸¸¿ˆÅ ˆÅ¸½ ‚¸¡¸º Age on operation day : œ¸º³«¸ Male ----- -------Ÿ¸¢í¥¸¸ Female ----- -----------

17. ‚¸¨¸½™ˆÅ ˆÅ¸ ˆÅ¸¡¸Ÿ¸ú œ¸÷÷¸¸ Permanent address of Applicant : ----------------------------------------------------------------------------------------------------------------------------------------------

18. ¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No. £½¥¸¨¸½ Rly.: ----- -----(Ÿ¸¸½.M) ----- -----------(™»£ž¸¸«¸ Land line) ----- ----------

19. Æ¡¸¸ ˆÅ.¢í.¢›¸. ¬¸½ œ¸»¨¸Ä Ÿ¸½ Ÿ¸™™ ¢Ÿ¸¥¸ú í¾ Whether any assistance sought from SBF earlier ( ¡¸¢™ í¸Â, ˆ¼Åœ¸¡¸¸ ¢¨¸¨¸£µ¸ ¢™¢¸‡ If yes, details �pl) :-------------------------------------------------------------

‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾ ‡¨¸¿ Ÿ¸½£ú ‡ˆÅ/™¸½ ¥¸”ˆÅú/¡¸¸ ¸ú¨¸ú÷¸ í¾, ¢ûÅ£� � ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½ ‚›¸º©¸¸¬¸›¸ ¨¸ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸� ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸ £í¿ºÁŠ¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge & i have on/two surviving girl child and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received. ________________________________________________ ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£ ¡¸¸ ‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸ Signature or thumb impression of the applicant¬’½©¸›¸ Station:____________¢™›¸¸¿ˆÅ Date: ____________¬¸¿¥¸Š›¸ Encl: ¨¸÷¸ÄŸ¸¸›¸ œ¸½ ¬¥¸úœ¸ ‡¨¸¿ œ¸£ú¨¸¸£ ¢›¸¡¸¸½¸›¸ ˆÅú ¬¸÷¡¸¸¢œ¸÷¸ œÏ�

¢÷¸ Current pay slip & Family Planning operation certificate

ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C- for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

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œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date --------------- ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal

2. ¹¬¨¸ˆ¼Å÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å ¢¥¸‡ for Sanctioning official :œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ —ˆÅŸ¸Ä¸¸£ú œ¸£ú¨¸¸£ ¢›¸¡¸¸½¸›¸ ž¸÷÷¸¸ ³œ¸¡¸¸� � ---------------¥¸½ £í¸ í¾ ‡¨¸¿ ¨¸÷¸ÄŸ¸¸›¸ œ¸½ ¬¥¸úœ¸ ¬¸½ ¢Ÿ¸¥¸¸›¸ ¢ˆÅ¡¸¸ Š¸¡¸¸ —Certified that all above particulars/ entries have been checked thoroughly and found correct. Employee is getting Family Planning Allowance Rs. --------------- & telly with current pay slip .

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ˆ½Å Å¢›¸¡¸Ÿ¸¸½ ˆ½Å ‚›¸º¬¸¸£ ™¸¨¸¸ ¬¸íú í¾ /¬¸íú ›¸íú í¾ Claim is� correct / in correct as per SBF terms & condition.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢¥¸¢œ¸ˆÅ Dealing clerk SBF �

™¸¨¸¸ Claim of ` ____________/- ˆÅ¸ ¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ / ‚¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ is approved / Rejected.

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

¨¸½÷¸›¸ ‚¸™½©¸ ¬¸¿‰¡¸¸ Pay order No. _____________________________________ ¢™›¸¸¿ˆÅ dated _______________

ˆÅ¸½ ¸¸£ú ¢ˆÅ¡¸¸ issued to �__________________________________________________________________.

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.15 SBF Form No.-15ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY

STAFF BENEFIT FUND‚¿Š¸ ¢¨¸Ž½™›¸ í¸½›¸½ œ¸£ ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸�

œ¸°¸ (ŠÏ½” œ¸½ ` 1800/- ¨¸ ¡¸¸™¸ ˆ½Å ¢¥¸‡)� Application form - financial assistance For Amputation from SBF for GP

Rs.1800/- and Above ( œ¸»¨¸ÄˆÅ¸¥¸ ˆ½Å ¨¸Š¸Ä ‘š¸’ ˆÅŸ¸Ä¸¸£ú ˆ½Å ¢¥¸‡ - ¸¸í½ „¸ ŠÏ½” œ¸½ ‡Ÿ¸‡¬¸úœ¸ú� � ��

Ÿ¸½¿ ¢™¡¸¸ Š¸¡¸¸ í¸½ ) (For Erstwhile Group ‘D’ Staff only- even higher GP issued in MACPS)

ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� (1) ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------(1) œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------(2) ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

(3) ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.------------------Working under----------------------------------------------------Pay bill Unit No----------------

(4) œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit-------------------------------------------------------

(5) Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit-----------------------------------------------------------(6) œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------(7) Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:---------------------

ž¸¸Š¸ - ¤¸ Section – B ¢¨¸¨¸£µ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ details for which � assistance saught:

12.ˆÅŸ¸Ä¸¸£ú ¬¨¸¿¡¸¿ ˆÅ¸ /‚¸¢ª÷¸ / ¤¸¸½ ›¸¸Ÿ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ Name of � �� �self /ward/dependant for whom assistance is sought:-----------------------------------------------------------------------------------------

13.ˆÅŸ¸Ä¸¸£ú ˆ½Å ¬¸¸˜¸ ¬¸¿¤¸¿š¸ Relationship with the �employee---------------------------------------------------

14.Æ¡¸¸ Ÿ¸£ú¸ œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ¬¸½ ©¸¢¬¸÷¸ í¾ ? If dependant is covered under pass rule? �---------------------------------

15.¢¨¸Ž½™ ˆÅ¸ œÏˆÅ¸£ Type of amputation:------------------------------------------------------------------�16.ƒ¥¸¸¸ ˆÅ¸ ¬˜¸¸›¸ Place of treatment:--------------------------------------------------------------------�17.Æ¡¸¸ ¢ûÅ¥¸í¸¥¸ ƒ¥¸¸¸ ¸¥¸ £í¸ í¾ Whether still undergoing � �

treatment:----------------------------------------18.Æ¡¸¸ ˆÅ.¢í.¢›¸. ¬¸½ œ¸»¨¸Ä Ÿ¸½ Ÿ¸™™ ¢Ÿ¸¥¸ú í¾ Whether any assistance sought from

SBF earlier ( ¡¸¢™ í¸Â, ˆ¼Åœ¸¡¸¸ ¢¨¸¨¸£µ¸ ¢™¢¸‡ If yes, details �pl) :---------------------------------------------------------------------------------

19. ‚œ¸¿Š¸÷¸¸ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ ˆÅú ¬¸÷¡¸¸¢œ¸÷¸ œÏ¢÷¸ Attested copy of disability certificate attached (í¸Â / ›¸íú Yes / NO) ------------

20. ‚œ¸¿Š¸÷¸¸ ˆÅ¸ ûŸ½’¸½ ¬¸¿¥¸Š›¸ ¢ˆÅ¡¸¸ í¾ — Photo graph of disability is enclosed (í¸Â / ›¸íú Yes / NO) ------------

(ˆ¼Åœ¸¡¸¸ ¸¸¥¸» Ÿ¸¸í ˆÅú œ¸½ ¬¥¸úœ¸ ¨¸ ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ / ™¬÷¸¸¨¸½¸� � � ¬¸¿¥¸Š›¸ ˆÅ£½¿ Kindly enclosed current pay slip & doctor's certificate / documents)

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‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾, ¢ûÅ£ ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½� � ‚›¸º©¸¸¬¸›¸ ¨¸ ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸ £í¿ºÁŠ¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received.

¬˜¸¸›¸ Place:¢™›¸¸¿ˆÅ Date:

ˆÅŸ¸Ä¸¸£ú ˆ½Å í¬÷¸¸®¸£� Signature of employees

ž¸¸Š¸ - ˆÅ Section – C £½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸� Recommendation of Railway Doctor :

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ „œ¸£¸½Æ÷¸ ™©¸¸¡¸½Ä ¨¡¸¢ˆÅ÷¸ ˆÅ½ ©¸£ú£ ˆ½Å �------------------------------------¢í¬¬¸½ ˆÅ¸ ‚¨¸¡¸¨¸ ˆÅ¸ ¢¨¸Ž½™ ¢ˆÅ¡¸¸ Š¸¡¸¸ í¾ .�It is certified that the above person had amputated ------------------------------------(part of body).

£½¥¸¨¸½ ¢¸¢ˆÅ÷¬¸ˆÅ ˆ½Å í¬÷¸¸®¸£ �¨¸ Ÿ¸¸½í£ Signature of Railway doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal

¢™›¸¸¿ˆÅ Date***

¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ ׸£¸ ¬¸¿¬÷¸º¢÷¸ ˆÅ£›¸¸ ¡¸¢™ í¸½ ÷¸¸½ Recommendation of � �NON Railway Doctor (If any)

¢›¸¸ú ¢¸¢ˆÅ÷¬¸ˆÅ � �ˆ½Å í¬÷¸¸®¸£ ¨¸ Ÿ¸¸½í£ Signature of private doctor & Seal¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ ›¸¸Ÿ¸� Name of DoctorÀ¢¸¢ˆÅ÷¬¸ˆÅ ˆÅ¸ œ¸™›¸¸Ÿ¸ � Designation of Railway Doctor :ˆÅ¸¡¸Ä ¬˜¸¥¸ ¨¸ Ÿ¸¸½í£ Place of working & seal ¢™›¸¸¿ˆÅ Date

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ž¸¸Š¸ - ” - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – D- for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , ƒ›¸ˆ½Å ׸£¸ œÏ¬÷¸»÷¸ ûŸ½’¸½ ¨¸¸¬÷¸¢¨¸ˆÅ í¾ —It is certified that all above particulars of the employee are verified by me & found correct & enclosed photo is as per physical condition.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal

2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Forwarding official to Headquarter:œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ —Certified that all above particulars/ entries have been checked thoroughly and found correct.

ˆÅŸ¸Ä¸¸£ú £¸¢©¸ � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ — Employee is eligible for amount ` -------------.

œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸¢š¸ ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢«¸÷¸ �¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½�¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal ¢™›¸¸¿ˆÅ Date:

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

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ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

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‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.16 SBF Form No.-16 ňş¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ œ¸¢©¸Ÿ¸ £½¥¸¨¸½ � � WESTERN RAILWAY STAFF BENEFIT FUND

™™úÄ ˆÅú ¥¸Ÿ¤¸ú ¢¤¸Ÿ¸¸£ú Ÿ¸½¿ ”¸¡¸œ¸£ ˆÅú ‚¸¨¸©¡¸Æ÷¸¸ ˆ½Å ¢¥¸‡ ‚¸¢˜¸ÄˆÅ Ÿ¸™™ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ œ¸°¸

Application form - financial assistance For Chronically ill patients requiring use of Diaper ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� (1) ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------(2) œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------(3) ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸ /¬’½©¸›¸-----------------------------

Department--------------------------------------------Station of working--------------------------(4) ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’

¬¸¿.------------------Working under----------------------------------------------------Pay bill Unit No----------------

(5) œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit-------------------------------------------------------

(6) Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit-----------------------------------------------------------(7) œ¸½ ¤¸½¿” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay----------------- Ÿ¸»¥¸ ¨¸½÷¸›¸ Basic

Pay----------(8) Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:---------------------

ž¸¸Š¸ - ¤¸ Section – B ¢¨¸¨¸£µ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ details for which � assistance saught:

(1) ˆÅŸ¸Ä¸¸£ú ¬¨¸¿¡¸¿ ˆÅ¸ /‚¸¢ª÷¸ / ¤¸¸½ ›¸¸Ÿ¸ ¢¸¬¸ˆ½Å ¢¥¸‡ Ÿ¸™™ Ÿ¸¸¿Š¸ú í¾ Name of self � �� �/ward/dependant for whom assistance is sought:-----------------------------------------------------------------------------------------

(2) ˆÅŸ¸Ä¸¸£ú ˆ½Å ¬¸¸˜¸ ¬¸¿¤¸¿š¸ Relationship with the �employee---------------------------------------------------

(3) Æ¡¸¸ Ÿ¸£ú¸ œ¸¸¬¸ ¢›¸¡¸Ÿ¸ ¬¸½ ©¸¢¬¸÷¸ í¾ ? If dependant is covered under pass rule? �---------------------------------

(4) ¢¤¸Ÿ¸¸£ú ˆÅ¸ œÏˆÅ¸£ Type of disease:------------------------------------------------------------------21. ƒ¥¸¸¸ ˆÅ¸ ¬˜¸¸›¸ Place of treatment:--------------------------------------------------------------------�

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22. Æ¡¸¸ ¢ûÅ¥¸í¸¥¸ ƒ¥¸¸¸ ¸¥¸ £í¸ í¾ Whether still undergoing treatment:----------------------------------------� �23. Æ¡¸¸ ˆÅ.¢í.¢›¸. ¬¸½ œ¸»¨¸Ä Ÿ¸½ Ÿ¸™™ ¢Ÿ¸¥¸ú í¾ Whether any assistance sought from SBF

earlier ( ¡¸¢™ í¸Â, ˆ¼Åœ¸¡¸¸ ¢¨¸¨¸£µ¸ ¢™¢¸‡ If yes, details �pl) :---------------------------------------------------------------------------------

‹¸¸½«¸µ¸¸ Declaration: - Ÿ¸ÿ š¸½¸«¸µ¸¸ ˆÅ£ £í¸ í» ¢ˆÅ „œ¸£¸½Æ÷¸ ž¸£¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ Ÿ¸½£ú ¸¸›¸ˆÅ¸£ú ˆ½Å ‚›¸º¬¸¸£ ¬¸íú í¾ ¾, ¢ûÅ£ ž¸ú ¡¸¢™ ˆÅ¸½ƒÄ °¸º’ú œ¸¸ƒÄ ¸¸÷¸ú í¾ ÷¸¸½ ‚›¸º©¸¸¬¸›¸ ¨¸� � ‚œ¸ú¥¸ ¢›¸¡¸Ÿ¸ ÷¸í÷¸ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å ¢¥¸‡ œ¸¸°¸ £í¿ºÁŠ¸¸ ¨¸ ¬¨¸úˆ¼Å÷¸ £¸¢©¸ œ¸º›¸À ¥¸¸¾’¸…Š¸¸ — I hereby declare that all particulars filled in above by me are true and correct to the best of my knowledge and in the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance amount, if sanctioned & received.

________________________________________________ ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£ ¡¸¸ ‚¿Š¸º“½ ˆÅ¸ ¢›¸©¸¸›¸ Signature or thumb impression of the applicant¬’½©¸›¸ Station:____________¢™›¸¸¿ˆÅ Date: ____________¬¸¿¥¸Š›¸ Encl: ¨¸÷¸ÄŸ¸¸›¸ œ¸½ ¬¥¸úœ¸ ‡¨¸¿ ¢¸¢Æ÷¸¬¸¸ ƒÄ¥¸¸¸ ˆÅ¸� �

ˆ½Å¬¸ Current pay slip & Medical treatment case

ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C- for Official Use 1. ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ¬¸½ ‚ŠÏ½¢«¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ , It is certified that all above particulars of the employee are verified by me & found correct.

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date --------------- ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date Ÿ¸¸½í£ Seal

2. ¹¬¨¸ˆ¼Å÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å ¢¥¸‡ for Sanctioning official :œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, „œ¸£¸½Æ÷¸ ƒÄ›Í¸¸ ¢¨¸¨¸£µ¸ ¬¸íú ÷¸£úˆ½Å ¬¸½ ¸¸¿¸ú� � � � Š¸ƒÄ í¾ ‡¨¸¿ ¬¸íú í¾ —Certified that all above particulars/ entries have been checked thoroughly and found correct.

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ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ˆ½Å Å¢›¸¡¸Ÿ¸¸½ ˆ½Å ‚›¸º¬¸¸£ ™¸¨¸¸ ¬¸íú í¾ /¬¸íú ›¸íú í¾ Claim is� correct / in correct as per SBF terms & condition.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢¥¸¢œ¸ˆÅ Dealing clerk SBF �

™¸¨¸¸ Claim of ` ____________/- ˆÅ¸ ¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ / ‚¬¨¸úˆ¼¼¼¼¼¼¼¼Å÷¸ is approved / Rejected.

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

¨¸½÷¸›¸ ‚¸™½©¸ ¬¸¿‰¡¸¸ Pay order No. _____________________________________ ¢™›¸¸¿ˆÅ dated _______________

ˆÅ¸½ ¸¸£ú ¢ˆÅ¡¸¸ issued to �__________________________________________________________________.

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.17 SBF-Form No.-17 ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸� STAFF BENEFIT FUND

¨¸«¸Ä 20 -20 ˆ½Å ¢¥¸‡ ¥¸”¢ˆÅ¡¸¸½¿ ˆÅ¸½ „¸ ¢©¸®¸¸ ˆÅ½�� ™¸¾£¸›¸ í¸½¬’½¥¸ ŠÏ¸¿’ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ œ¸°¸

Application form for Hostel Grant to Girl child for higher education for the year 20__-20 ___

ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

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Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.-------------------Working under----------------------------------------------------Pay bill Unit No-----------------

5. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit--------------------------------------------------------

6. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit------------------------------------------------------------7. œ¸½ ¤¸½¿›” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay-----------------Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------8. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:--------------------9. Æ¡¸¸ œ¸í¥¸ú ¤¸¸£ ›¸¡¸½ ˆ½Å ¢¥¸‡ ¡¸¸ ›¸¨¸ú›¸úˆÅ£µ¸ ¡¸¸ ™»¬¸£ú ¡¸¸ ‚¢š¸ˆÅ ¤¸¸£ ˆ½Å ¢

¥¸‡ ‚¸¨¸½™›¸ ¢ˆÅ¡¸¸ : -----------------------------Whether applied for New (1st time) / Renewal(2nd or more time) : -----------------------------------

10.¡¸¢™ ›¸¨¸ú›¸úˆÅ£µ¸ í¾, œ¸úŽ¥¸½ ¨¸«¸Ä ˆÅú ¢¬¨¸ˆ¼Å÷¸ £¸©¸ú If renewal, than specify last time amount sanctioned: `---------

11.¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No.£½¥¸¨¸½ Rly.:_____________(Ÿ¸¸½. M) ____________(™»£ž¸¸«¸ Land line)____________

ž¸¸Š¸ - ¤¸ Section – B - í¸½¬’½¥¸ Ÿ¸½¿ £í›¸½¨¸¸¥¸ú ¥¸”ˆÅú ˆÅ¸ ¢¨¸¨¸£µ¸ Details of Girl child residing in hostel

1. Ž¸°¸/¤¸¸ú ˆÅ¸ ›¸¸Ÿ¸ Name of the student / Ward --------------------------------------------------------��2. ˆÅŸ¸Ä¸¸£ú ¬¸½ ¬¸¿¤¸¿š¸ Relationship with the employee �

------------------------------------------------------3. ¬¸º¢¨¸š¸¸ œ¸¸¬¸ ˆ½Å œ¸¸°¸ í¾ ¡¸¸ ›¸íú Whether eligible for passes or not

------------------------------------------4. Æ¡¸¸ ©¸¸™ú©¸º™¸ í¾ ¡¸¸ ‚¢¨¸¨¸¸íú÷¸ Whether married or unmarried

---------------------------------------------5. ˆÅ¸Á¥¸½¸ í¸½¬’½¥¸ /¬¸¿¬˜¸¸ ˆÅ¸ ›¸¸Ÿ¸ ¸í¸Â £í £íú í¾ Name of college Hostel /Institute � �

where residing--------------------------6. œ¸¸“á¸ÇÅŸ¸ ˆÅú ‚¨¸¢š¸ Total duration of course-----------¨¸«¸Ä Years--------------

¬¸½Ÿ¸ú¬’£ Semesters-----------7. œ¸¸“á¸ÇÅŸ¸ ˆÅ¸ ›¸¸Ÿ¸ Name of the course---------------------------------------------------------------8. œ¸¸“á¸ÇÅŸ¸ ˆÅú ¢¬˜¸¢÷¸ Stage of study during ¨¸«¸Ä year 20___- 20

___:----------------------------------9. œ¸¸“á¸ÇÅŸ¸ ˆ½Å ‚¿÷¸ Ÿ¸½¿ ¸¸£ú í¸½›¸½¨¸¸¥¸ú ”úŠÏú /”úœ¥¸½Ÿ¸¸ ˆÅ¸ ›¸¸Ÿ¸ Name of �

Degree/Diploma certificate awarded on completion of course by the University -------------------------------------------------------------

10.Æ¡¸¸ ¡¸í ¢”ŠÏú /œ¸¸½¬’ ŠÏ½¡¸º¡¸½’ /”úœ¥¸¸½Ÿ¸¸ ˆÅ¸ ˆÅ¸½¬¸Ä í¾ Whether it is �Degree/Post graduate/Diploma Course----------

11.‚¿¢÷¸Ÿ¸ „÷÷¸úµ¸Ä œ¸£ú®¸¸ Name of last exam passed----------------------------------------------------------

12.œÏ¸œ÷¸ ‚¿ˆÅ Total marks obtained -----------------------------ˆºÅ¥¸ ‚¿ˆÅ Ÿ¸ ¬¸½ Out of-----------------------œÏ¸œ÷¸ ‚¿ˆÅ Total marks obtained -----------------------------ˆºÅ¥¸ ‚¿ˆÅ Ÿ¸ ¬¸½ Out of-----------------------

(¡¸¢™ ¬¸½Ÿ¸ú¬’£ œ¸‹š¸¢÷¸ í¾ ÷¸¸½ œÏ÷¡¸½ˆÅ ˆÅ¸½ ‚¥¸Š¸ ™©¸¸¡¸½¿ In case of Semester system, please mention marks of each semester separately)13.‚¿ˆÅ¸½ ˆ½Å œÏ¢÷¸©¸÷¸ Percentage of

marks-----------------------------------------------------------------14.Æ¡¸¸ ¨¸¸¢«¸ÄˆÅ ‡¨¸¿ ÷¸Ÿ¸¸Ÿ¸ ¬¸½Ÿ¸ú¬’£ œ¸£ú®¸¸ Ÿ¸½¿ „÷¸úĵ¸ í¾

---------------------------------------------------Whether result declared passed in all Semester/Annual Exam.---------------------------------------

¬¸¿¥¸Š›¸ / EnclÀ 1. ¬ˆ»Å¥¸ / ˆÅ¸Á¥¸½¸ /Š¸½¸½¿’½” ‚¢š¸ˆÅ¸£ú ׸£¸ ¬¸÷¡¸¸¢œ¸÷¸,� � „÷¸úĵ¸ í¸½›¸½¨¸¸¥¸ú ‚¿ˆÅ÷¸¸¢¥¸ˆÅ¸ ˆÅú œÏ¢÷¸ Copy of passing mark sheet attested by School/College authority/ Gazatted Officer 2. í¸½¬’½¥¸ ˆ½Å ™¸¢‰¸¥¸½ ˆÅ¸ œÏŸ¸¸µ¸œ¸°¸ Hostel admission certificate.

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œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ ™ú Š¸ƒÄ Ÿ¸½£½ ׸£¸ ™ú Š¸ƒÄ ¸¸¸›¸ˆÅ¸£ú ¬¸íú í¾.� � Certified that the information given by me is correct. ƒ¬¸ˆ½Å ¨¸¸¨¸¸»™ ˆÅ¸½ƒÄ ‚¢›¸¡¸�¢Ÿ¸÷¸÷¸¸ ¡¸¸ ¬¸÷¡¸÷¸¸ Žºœ¸¸ƒÄ í¸½ ÷¸¸½ Ÿ¸ÿ ‚›¸º©¸¸¬¸¢›¸ˆÅ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å œ¸¸°¸ £íºÂŠ¸¸ ‡¨¸¿ ¬¨¸úˆ¼Å÷¸ Ž¸°¸¨¸¼¢÷¸ ˆÅ¸½ œ¸º›¸À¥¸¸¾’¸…¿Š¸¸ In the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the scholarship if sanctioned & received. ¬˜¸¥¸ Place À¢™›¸¸¿ˆÅ Date À

ˆÅŸ¸Ä¸¸£ú ˆ¿½Å í¬÷¸¸®¸£ Sign of �the employee -------------------

ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C - for Official Use 1. ‚ŠÏ½¢¬¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official It is certified that all above particulars of the employee are verified by me & found correct.œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ ,

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------¢™›¸¸¿ˆÅ Date:Ÿ¸¸½í£ Seal 2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢¬¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ For Forwarding official to Headquarter:ˆÅŸ¸Ä¸¸£ú ›¸½ ¸½ˆÅ ¥¸ú¬’ ‚›¸º¬¸¸£ ¬¸ž¸ú ™¬÷¸¸¨¸½¸ ¬¸¿¥¸Š›¸ ¢ˆÅ¡¸½ í¾ , ‡¨¸¿ £¸¢©¸ � � � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ — Employee has submitted all required documents as per check list & eligible for amount ` -------------.

œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸š¸ú ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢¬¸÷¸ ˆÅú �¸¸÷¸ú í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½¢¬¸÷¸ �ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£ Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal¢™›¸¸¿ˆÅ Date:

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

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‚›¸º¤¸¿š¸ “ ‚ ” Annexure “ A ”

¨¸«¸Ä 20 -20 ˆ½Å ¢¥¸‡ ¥¸”¢ˆÅ¡¸¸½¿ ˆÅ¸½ „¸ ¢©¸®¸¸ ˆÅ½�� ™¸¾£¸›¸ í¸½¬’½¥¸ ŠÏ¸¿’ ˆ½Å ¢¥¸‡

í¸½¬’½¥¸ / ¬¸¿¬˜¸¸ ˆ½Å œÏŸ¸»‰¸ ׸£¸ œÏŸ¸¸¢µ¸÷¸ ˆÅ£›¸½ ˆÅ¸ œÏœ¸°¸

Application form for Hostel Grant to Girl child for higher education œ¸¢©¸Ÿ¸ £½¥¸¨¸½ ¬¸½ Ž¸°¸¨¸¼¢÷¸ œ¸¸›¸½ ˆ½Å ¢¥¸‡ ˆÅÁ¸¥¸½¸ œÏŸ¸»‰¸ ׸£¸� �

œÏŸ¸¸¢µ¸÷¸ ˆÅ£›¸½ ˆÅ¸ œÏœ¸°¸ Form to be certified by Head of the Hostel/ Institution of Hostel

For claiming Hostel Grant for the year 20__-20 ___(›¸¸½’ Note- ›¸Ÿ¸»›¸½ Ÿ¸½¿ ¤¸™¥¸¸¨¸ £Ó¤¸¸™¥¸ ˆ½Å œ¸¸°¸ í¾ Alteration/deletions in the

Performa will lead to rejection)

œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ Certified that ˆºÅŸ¸¸£ú� Miss--------------------------------------------------------------- œ¸º°¸ú daughter of ªú /ªúŸ¸¸›¸ Shri/Smt-------------------------------------------------------------------------------------------------------- ƒ¬¸ í¸½¬’½¥¸ ˆÅú ¢›¸¡¸¢Ÿ¸÷¸ Ž¸°¸¸ í¾ is bonafide member of this Hostel ¸¸½ ¢ˆÅ ׸£¸ ¸¥¸¸ƒÄ� � ¸¸ £íú í¾ which run by� ------------------------------------------------------------------------------------------------------------------------------------------------í¸½¬’½¥¸ Ž¸°¸¸ ˆÅ¸ ¢¨¸¨¸£µ¸ £úˆÅ¸”Ä ‚›¸º¬¸¸£ Particulars of this student as per record of hostel are as under:1 œ¸¸“á¸ÇÅŸ¸ ˆÅ¸ œ¸»£¸ ›¸¸Ÿ¸ Name of course (In full) ------------------------------------------------------------- 2 í¸½¬’½¥¸ Ÿ¸½¿ œÏ¸˜¸¢Ÿ¸ˆÅ ™¸¢‰¸¥¸½ ˆÅú ÷¸¸£ú‰¸ Date of initial admission------------------------------------------------------3 œ¸¸“á¸ÇÅŸ¸ ˆÅú ¢¬˜¸¢÷¸ Stage of study during ¨¸«¸Ä year 20___- 20 ___:------¨¸«¸Ä year-------¬¸½Ÿ¸ú¬’£ semester4 í¸½¬’½¥¸ ¬¸°¸ Hostel session ¨¸«¸Ä Year 20___-20____: ©¸²‚¸÷¸ starts ˆÅ¤¸ ¬¸½ from------------ˆÅ¤¸ ÷¸ˆÅ to-----------

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5. œÏ¢÷¸ ¨¸«¸Ä œÏ¸œ÷¸ ˆºÅ¥¸ í¸½¬’½¥¸ ûÅú¬¸ ˆÅú £¸¢©¸ Total amount of Hostel fees received per annum `-------------------œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ „œ¸£¸½Æ÷¸ Ž¸°¸¸ ˆÅ¸ ¢¨¸¨¸£µ¸ í¸½¬’½¥¸ /¬¸¿¬˜¸¸ ˆ½Å� œÏ¸¢š¸ˆÅ¸£ú ›¸½ ¸¸¿¸¸ í¾ ‡¨¸¿ ¬¸íú œ¸¸¡¸¸ í¾ — It is certified that all the above particulars� � of above student are verified by Hostel / Institution Authority and found correct.

í¸½Å¬’½¥¸ / ¬¸¿¬˜¸¸ ˆ½Å œÏŸ¸º‰¸ ˆ½Å í¬÷¸¸®¸£ Signature of the Head of Hostel/ Institute

›¸¸Ÿ¸ Name : ___________________________________________________ œ¸™›¸¸Ÿ¸ Designation:

_____________________________________________

í¸½¬’½¥¸ / ˆÅ¸Á¥¸½¸ ˆÅú Ÿ¸¸½í£ Hostel/ Collage Seal�

¬˜¸¥¸ Place À¢™›¸¸¿ˆÅ Date À

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �

‡¬¸¤¸ú‡ûÅ ›¸Ÿ¸»›¸¸ ¬¸¿.18 SBF-Form No.-18 ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸� STAFF BENEFIT FUND

‚›¸¸˜¸ ¥¸”ˆÅú ˆÅ¸½ ™÷÷¸ˆÅ/Š¸¸½™ ¥¸½›¸½ œ¸£ ‚¸¢˜¸ÄˆÅ ¬¸í¸¡¸ ˆ½Å ¢¥¸‡ ‚¸¨¸½™›¸ œ¸°¸

Application form for Financial Assistance for Adoption of orphan girl child

ž¸¸Š¸ - ‚ Section – A ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Employee details:� 1. ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ À-------------------------------------------------------------------------------------�

Name of the employee (in BLOCK LETTERS) -----------------------------------------------------2. œ¸™›¸¸Ÿ¸ À----------------------------------------------------œ¸ú‡ûÅ /œÏ¸›¸ ¬¸¿.----------------------------

Designation -----------------------------------------------PF/PRAN No --------------------------3. ¢¨¸ž¸¸Š¸ À------------------------------------------------ˆÅ¸¡¸Ä ¬˜¸¥¸

/¬’½©¸›¸-----------------------------Department--------------------------------------------Station of working--------------------------

4. ¢ˆÅ¬¸ ˆ½Å ÷¸í÷¸ ˆÅ¸¡¸Ä£÷¸ ------------------------------------------------- -œ¸½ ¢¤¸¥¸ ¡¸»¢›¸’ ¬¸¿.-------------------Working under----------------------------------------------------Pay bill Unit No-----------------

5. œ¸½ ¢¤¸¥¸ ¤¸›¸¸¸›¸½¨¸¸¥¸ú ¡¸»¢›¸’ Pay sheet preparing Unit--------------------------------------------------------

Page 47: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

6. Ÿ¸¿”¥¸ /¡¸»¢›¸’ ˆÅ¸ ›¸¸Ÿ¸ Name of Division/Unit------------------------------------------------------------7. œ¸½ ¤¸½¿›” Pay Band-----------------------ŠÏ½” œ¸½ Grade Pay-----------------Ÿ¸»¥¸ ¨¸½÷¸›¸

Basic Pay----------8. Æ¡¸¸ ‚¸œ¸ ‡¬¸¬¸ú/‡¬¸’ú/‚¸½¤¸ú¬¸ú/¬¸¸Ÿ¸¸›¡¸ ¸¸¢÷¸ ˆ½Å í¸½ Whether belongs to �

SC/ST/OBC/GEN:--------------------9. ¬¸¿œ¸ˆÄÅ ¬¸¿‰¡¸¸ Contact No.£½¥¸¨¸½ Rly.:_____________(Ÿ¸¸½. M)

____________(™»£ž¸¸«¸ Land line)____________

ž¸¸Š¸ - ¤¸ Section – B - ‚›¸¸˜¸ ¥¸”ˆÅú ¢¸¬¸½ ™÷÷¸ˆÅ/Š¸¸½™ ¢¥¸¡¸¸ í¾ „¬¸ˆÅ¸ � ¢¨¸¨¸£µ¸ Details of orphan Girl child adopted :

1. ™÷÷¸ˆÅ ¤¸¸ú ˆÅ¸ ›¸¸Ÿ¸ Name of the girl child adopted ��--------------------------------------------------------

2. ˆÅ¸½’Ä ¬¸½ ™÷÷¸ˆÅ ¥¸½›¸½ ˆÅú ¢™›¸¸¿ˆÅ Date of Adoption by court :--------------------------------------------------

3. ™÷÷¸ˆÅ ¤¸¸ú ˆÅú ¸›Ÿ¸ ¢™›¸¸¿ˆÅ Date of birth of adopted childÀ----------------------------‚¸¡¸º�� � Age--------------

4. ¬¸¿¬˜¸¸ ˆÅ¸ ›¸¸Ÿ¸ ¸í¸Â ¬¸½ ™÷÷¸ˆÅ ¢¥¸¡¸¸ Š¸¡¸¸ í¾ Name of institute from where gorl �child adopted(™¬÷¸¸¨¸½¸ ¬¸¿¥¸Š›¸ ˆÅ£½¿ Encl documents) �--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

¬¸¿¥¸Š›¸ / EnclÀ 1. Copy of Legal adoption documents of court. Notary documents are not valid.2. Copy of memorandum of administration to accept adoption as family member.3. Copy of Medical card with name of adoptee orphan girl child.

. œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ ™ú Š¸ƒÄ Ÿ¸½£½ ׸£¸ ™ú Š¸ƒÄ ¸¸¸›¸ˆÅ¸£ú ¬¸íú í¾.� � Certified that the information given by me is correct. ƒ¬¸ˆ½Å ¨¸¸¨¸¸»™ ˆÅ¸½ƒÄ ‚¢›¸¡¸�¢Ÿ¸÷¸÷¸¸ ¡¸¸ ¬¸÷¡¸÷¸¸ Žºœ¸¸ƒÄ í¸½ ÷¸¸½ Ÿ¸ÿ ‚›¸º©¸¸¬¸¢›¸ˆÅ ˆÅ¸¡¸Ä¨¸¸íú ˆ½Å œ¸¸°¸ £íºÂŠ¸¸ ‡¨¸¿ ¬¨¸úˆ¼Å÷¸ ‚¸¢˜¸ÄˆÅ ¬¸í¸¡¸÷¸¸ ˆÅ¸½ œ¸º›¸À¥¸¸¾’¸…¿Š¸¸ In the event of any irregularity or concealment of fact, I will render myself liable for DAR action and refund the financial assistance if sanctioned & received.

¬˜¸¥¸ Place À¢™›¸¸¿ˆÅ Date À

ˆÅŸ¸Ä¸¸£ú ˆ¿½Å í¬÷¸¸®¸£ Sign of �the employee -------------------

ž¸¸Š¸ - ˆÅ - ˆÅ¸¡¸¸Ä¥¸¡¸ „œ¸¡¸¸½Š¸ ˆ½Å ¢¥¸‡ Section – C - for Official Use 1. ‚ŠÏ½¢¬¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å ¢¥¸‡ for Unit In-charge Forwarding official It is certified that all above particulars of the employee are verified by me & found correct.œÏŸ¸¸¢µ¸÷¸ ¢ˆÅ¡¸¸ ¸¸÷¸¸ í¾ ¢ˆÅ, ˆÅŸ¸Ä¸¸£ú ˆÅ¸ ¢¨¸¨¸£µ¸ Ÿ¸½£½ ׸£¸ ¸¸¿¸¸ Š¸¡¸¸ í¾ � � � �‡¨¸¿ ¬¸íú í¾ ,

‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆ½Å í¬÷¸¸®¸£ Unit In-charge ----------------------------¢™›¸¸¿ˆÅ Date ‚›¸ºž¸¸Š¸ œÏž¸¸£ú ˆÅ¸ ›¸¸Ÿ¸ Unit In-charge -------------------------------------œ¸™›¸¸Ÿ¸ Designation---------------

Page 48: wr.indianrailways.gov.in · Web viewApplication form For Financial Assistance to Physically / Mentally challenged wards especially Girl of Railway employee for Training for developing

¢™›¸¸¿ˆÅ Date:Ÿ¸¸½í£ Seal 2. Ÿ¸º‰¡¸¸¥¸¡¸ ‚ŠÏ½¢¬¸÷¸ ˆÅ£›¸½¨¸¸¥¸½ ˆ½Å ¢¥¸‡ For Forwarding official to Headquarter:ˆÅŸ¸Ä¸¸£ú ›¸½ ¸½ˆÅ ¥¸ú¬’ ‚›¸º¬¸¸£ ¬¸ž¸ú ™¬÷¸¸¨¸½¸ ¬¸¿¥¸Š›¸ ¢ˆÅ¡¸½ í¾ , ‡¨¸¿ £¸¢©¸ � � � ` --------------------ˆÅ¸ œ¸¸°¸ í¾ — Employee has submitted all required documents as per check list & eligible for amount ` -------------.

œÏˆÅ£µ¸ ˆ½Å›Íú¡¸ ˆÅŸ¸Ä¸¸£ú ¢í÷¸ ¢›¸š¸ú ¬¸¢Ÿ¸¢÷¸ ˆ½Å ¢›¸µ¸Ä¡¸ ˆ½Å ¢¥¸‡ ‚ŠÏ½¢¬¸÷¸ ˆÅú �¸¸÷¸ú í¾ —�Case forwarded to Central Staff Benefit Fund Committee for decision.

ˆÅŸ¸Ä¸¸£ú ¢í÷¸¢›¸¢š¸ ¢›¸£ú®¸ˆÅ ˆ½Å í¬÷¸¸®¸£ ˆÅ¸¢Ÿ¸ÄˆÅ /‚ŠÏ½¢¬¸÷¸ �ˆÅ£›¸½¨¸¸¥¸½ ‚¢š¸ˆÅ¸£ú ˆ½Å í¬÷¸¸®¸£ Signature of dealing SBF clerk/inspector Signature of Personnel /forwarding Officer›¸¸Ÿ¸ Name ›¸¸Ÿ¸ Nameœ¸™›¸¸Ÿ¸ Designation œ¸™›¸¸Ÿ¸ DesignationŸ¸¿”¥¸ /ˆÅ¸£‰¸¸›¸¸ Division/workshop ˆÅ¸¡¸¸Ä¥¸¡¸ ¬¸¿œ¸ˆÄÅ ¬¸¿. Office contact No. ˆÅ¸¡¸¸Ä¥¸¡¸ Ÿ¸¸½í£ Office seal¢™›¸¸¿ˆÅ Date:

ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ ˆÅ.¢í.›¸ú.-‚š¡¸®¸�SBF Member SBF Member SBF Member SBF Member SBF Secretary Chairman-SBF¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS

ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸™¬¡¸ ˆ½Å.ˆÅ.¢í.›¸ú.-¬¸¢¸¨¸ �CSBF Member CSBF Member CSBF Member CSBF Member CSBF Secretary ¨¸½£½‡¡¸»WREU ¨¸½£½‡¡¸WREU ¨¸½£½Ÿ¸¬¸¿WRMS ¨¸½£½Ÿ¸¬¸¿WRMS „œ¸ Ÿ¸º.ˆÅ¸.‚.(ˆÅ)-¸¸ÄŠ¸½’ Dy.CPO(W)-CCG� �