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Annexure-A-I

APPLICATION FORM FOR CERTIFICATE FOR AN APPLICANT WHOSE FATHER HAS DIED

To

The Naib Tehsildar/Tehsildar

____________________________

Sub:- CERTIFICATE FOR AN APPLICANT WHOSE FATHER HAS DIED.

1 Name of applicant (IN BLOCK LETTERS)

2 Date of Birth (enclose proof)

3 Age of applicant at the time of father death

4 Applicant is first or second child

5 Present Address, Village

6 Post Office

7 Police Station

8 District

9 Caste

10 Father’s Name

11 Date of birth of father

12 Age of father at the time of his death

13 Date of father’s Death (enclose death

certificate)

14 Mother’s Name

15 Occupation

16 Aadhar No/PAN Card No/Voter Id No ( if any)

Please issue me a “Certificate for an applicant whose father has died.

Signature of applicant

Place:

Date:

Signature and Address of Witness

i)

ii)

VERIFICATION

I

__________________________,s/o____________________,Member Panchayat/Sarpanch/Councilor/MLA/MP

of concerned Village/area/constituency _______________ verified personally and statement furnished by

the applicant are correct to the best of my knowledge and belief.

Signature with seal of Member Panchayat/Councilor/MLA/MP

of the concerned Village/area/constituency

Annexure-A-II

GOVERNMENT OF HARYANA

Certificate for an applicant whose father has died

No____________________________________________________Date_______________________________

Certified that the person with the details mentioned below is an applicant whose father has

died-:

1 Name of applicant(IN BLOCK LETTERS)

2 Date of Birth(enclose proof)

3 Age of applicant at the time of father death

4 Applicant is first or second child

5 Present Address, Village

6 Post Office

7 Police Station

8 District

9 Caste

10 Father’s Name

11 Date of birth of father

12 Age of father at the time of his death

13 Date of father’s Death (enclose death

certificate)

14 Mother’s Name

15 Occupation

16 Aadhar No/PAN Card No/Voter Id No ( if any)

This certificate is issued based on the details given in the application, local enquiry, facts and

records produced by the applicant.

Signature with seal of the Naib Tehsildar/Tehsildar

Annexure-B-I

APPLICATION FORM FOR WIDOW CERTIFICATE

To

The Naib Tehsildar/Tehsildar

____________________________

Sub:- Issuance of Widow Certificate.

I ............................................., Widow of Sh....................................... hereby give my

particular as under:-

1 Name of Applicant (IN BLOCK LETTERS)

2 Address

3 Village

4 Tehsil

5 District

6 Post office with PIN Code

7 Name of Father/Mother

8 Name of Husband

9 Date of Death of Husband (Death Certificate to

be attached)

10 Aadhaar No. (if any)/PAN Card No. (if

any)/Voter ID No. (if any)

Please issue me a “WIDOW” Certificate.

Signature of Applicant

Place:

Date:

VERIFICATION

I...............................s/o, d/o, w/o,............................, Member Panchayat /Sarpanch

/Councilor/ MLA/MP of concerned Village/area/constituency......................................

verified personally and statement furnished by the applicant are correct to the best of my

knowledge and belief.

Signature with seal of Member

Panchayat/Sarpanch/Councilor/MLA/MP of the concerned Village

area/ constituency

Annexure-B-II

GOVERNMENT OF HARYANA

WIDOW Certificate

No____________________________________________________Date________________________________

Certified that the person with the details mentioned below is a Widow.

1. Name (IN BLOCK LETTERS)

2. Address

3. Village

4. Tehsil

5. District

6. Post office with PIN Code

7. Name of Father/Mother

8. Name of Husband

9. Date of Death of Husband

10. Aadhaar No./PAN Card No./Voter ID No. (if

any)

This certificate is issued based on the details given in the application,

Verification Report, local enquiry, facts and records produced.

Signature with seal of the Naib Tehsildar/Tehsildar

Annexure-D-I

Experience Certificate

1. This is to certify that Shri /Smt/Ms/Kumari, .............................................................

Son/ daughter/ wife of Shri ..................................................................................

resident of ....................................................... village/town .................................

Tehsil .............................................................. District .............................................

of Haryana State/Union Territory has been serving as ..............................................

(Complete nomenclature of the post in the office of ....................................................

(Department/ Board /Corporation /Company/ Statutory Body / Commission /

Authority of Government of Haryana or any State Government or Government of

India.)

2. The period of engagement was from............................................................................

to ............................................................................... and the completed years and

months are ................................................................... (years & months.)

3. The EPF account no. (if any) is /was..................................................................

Place: Signature with seal of Issuing Authority (Head of Office)

Date: Full Name

Designation

Address

Telephone No. With code

Annexure-E-I

UNDERTAKING

I........................................,Son/Daughter of.................................................

aged.........................................,years,R/o.......................................................................,

District .........................................., do hereby submit the following information for claiming

marks under the Socio-economic criteria namely:-

(1) That I am to apply for the post of ............................................................ in HSSC

against Category No. ..............................................., Advt.No.

................................................., Dated ...............................................

(2) That my Aadhaar No. / PAN Card No. / Voter ID No. (if any) is

................................................,

(3) That neither the applicant nor any person among the applicant’s family viz. father,

mother, spouse, brothers and sons is, was or has been a regular employee in any

Department / Board / Corporation/ Company/ Statutory Body/ Commission /

Authority of Government of Haryana or any other State Government or Government of

India.

(4) That as no person as mentioned above had been in employment, I may be allotted

marks under the socio-economic criteria.

(5) That I fully understand that the marks are given on the basis of information supplied

by me and if at any stage it is found that the information has been provided wrongly

then not only my service can be terminated on the ground of supply of wrong

information even if without these marks also my name would have figured within the

select list / recommendation list. I also understand that criminal action can be taken

against me for providing wrong / false information.

(6) That the deponent shall not take advantage of the certificate(s) issued by the

Competent Authority if in meantime any other eligible person in my family obtains the

benefits thereof in the recruitment.

Place:- DEPONENT

Date:-

VERIFICATION:-

Verified that the contents of all the above paras are true to my

knowledge and belief and nothing has been concealed therein.

Place:- DEPONENT

Date:-