Family declaration on Medical

1.

Name of Govt. Servant:

2.

Designation:   

3.

Date of Birth:

4.

Date of appointment:

5.

Details of the member of my family as on:

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Name of the member of my family

Date of Birth

Relationship with the official

Initial of the head of office

Remarks

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2.

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I here by undertake the above particulars update by notifying to the Audit Officer/ Head of Office any addiction of alteration.

Dated:

Signature of the Govt. Servant

Family for this purpose means:

(a)

Wife, in the case of Male Govt. Servant

(b)

Husband, in the case of Female Govt. Servant

(c)

Parents, Children and Step-children wholly depend upon the Govt. Servant

(d)

Sister, Windowed sisters, Windowed daughters, Minor brothers, wholly depend upon the Govt. Servant.

COUNTER SIGNED: