GOVERNMENT OF SIKKIM

OFFICE OF THE WELFARE OFFICER ( N/S/E/W )

SOCIAL JUSTICE, EMPOWERMENT AND WELFARE DEPARTMENT

GANGTOK

APPLICATION FORM FOR GRANT OF OLD AGE PENSION

1. Name of the applicant ( in block letters ):- ……….………………………

2. Father’s / Husband’s name:- ………………………………..

3. Date of Birth :- ………………………………..

4. Whether Husband / wife is recipient

of old age pension :- ……………………………….

5. Name of the ward :- ………………………………..

6. Name of the G.P.U. :- ………………………………..

7. Name of the Constituency :- ……………………………….

8. Sub – Division :- ……………………………….

9. District :- ……………………………….

10. Name of the Children Age Occupation

11. Name of the Deceased person who

was receiving the Old Age Pension ………………………………..

The information given above are true to the best of my behalf and knowledge. Further, if any time the Department finds that the information given above are / is incorrect, I agree to surrender the passbook issued to me under these rules.

Signature or thumb impression of the applicant

Required Documents :-

i) 3 recent passport sized photographs

ii) Attested copy of Sikkim subject / COI

iii) Attested copy of BPL Certificate

iv) Copy of electoral card

The applicant is ------------------------- years and belongs to BPL Family and is hereby recommended for selection under OAP Scheme as resolved by the Gram Sabha held on -------

Signature & Seal of the president and

Members of the Gram Sabha

M.L.A. RECOMMENDATION

Application of the applicant is hereby recommended.

Signature ………………………..

Seal ………………………………

For official use only

Application received along with

1. Pass photo ……………………… identification
2. Sikkim subject / Certificate of identification
3. BPL certificate / vikash patrika photocopy