GOVERNMENT ORDER NO. SWL 5 SWW 84, DT. 14-12-1985.

APLICATION FOR DESTITUTE WIDOW PENSION

District _________________________________
Taluka _________________________________

PHOTO

Village _________________________________
Town

1
2
3
4

_________________________________

Name of the widow in full with

alies (block letters)
Date of Birth and Age

Particulars of documents
enclosed in support of age
Full Postal Address
a) Temporary
b) Permanent

:
:
:

No. of Children if any & their ages :

(Sons & daughters with full
names & occupation)
1)
2)
3)
4)
5)

6
7
8
9

10
11
12
13
14
15

16

Father/Mothers Name and

Address
Name & how her husband died is
available with date
When & address of the deceased
husband
Name & address of the Father-inlaw & Mother-in-law & their
occupation
Present occupation of the
applicant
Physical defects if any

Whether the applicant belongs to

SC/ST
Educational Qualification

Whether Insurance if so
approximate amount
Whether owns any landed
property & any other immovable
property give with details
No. of depends to support and
their relationship with age.

Date:

:
:

:
:

R.C. Office / N.I.C. Office, Belgaum

17

18

19
20

21
22

Certificate from responsible

persons whom he knows in the
locality
Total income of the widow per
annum, whether the income
certificate issued by the
Tahasildar is enclosed
Have you ever received pension
under any Scheme?
If Yes give details of
a) Period for which pension paid
b) Amount received per annum
c) Reasons for discount pension
Documents attached

:
:

:
:

23

Are you insterested of pension

from any other Scheme
If Yes give details

24

Indentification Mark

25

Details of the applicant/relatives/ :

guardian/charitableness.
Whether any of the relatives if
:
continously missing. If so the
details
I hereby certify that
:

26

27

28

a) I have no source Income for

living
b) I have earlier not submitted
any application for grant pension
c) I am a native of Karnataka
State and I am domicilled by the
Karnataka State by Birth
d) I am not in receipt of monthly
maintenance allowance payable of
physically handicapped pension.
e) All the Particulars furnished by
me are correct to the best of my
knowledge.
If any information furnished by
:
me is found at any time to be
untrue, I hereby undertake to
repay the Govt. the pension
drawn by me.

Place:

This LHTI of

Date:
Signature of the applicant

R.C. Office / N.I.C. Office, Belgaum

CERTIFICATE
I know Smt. ____________________________________________ Wife of late
Shri. ____________________________________________________________ for the
last ____________________________ years. I certify that the information
furnished by is correct to the best of my personal knowledge.
[1]

[2]

Signature of the person

who given certificate with
address & with designation
This certificate shall be furnished by a member of Loksabha,
Rajyasabha, Lagislative assembly, Lagislative Council, Munciple Council,
Corporation Councilor or a Panchayat Chairman or the Manager of poor
case

of

similars

Charitable

Institution

of

Gazatted

Officer

of

the

State/Central Government.
WIDOW CERTIFICATE
This is to certify that Smt. __________________________________________
____________________________________ is known to me. Her Husband late
Shri. _____________________________________________________________________
expired on ___________________ at ________________________________________
______________________________________ She had __________________________
Children at the time of his death.

Place:
Date:
Signature with Designation
Widow Certificate from the registrar of Births and Deaths of any
pension authorised by the registrar of Births and Deaths in case where
Verification is not traceable a Certificate shall be obtained from the
concerned Panchayat Chariman / Counciler of Corporation, M.L.A. for the
proof that her husband had died and Children at the time of her Husbands
death.

R.C. Office / N.I.C. Office, Belgaum

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R.C. Office / N.I.C. Office, Belgaum