APPLICATION FORM

(Please paste court fee stamp here)

DEPENDENT CERTIFICATE
Fields marked with (*) are mandatory

Details of Letter from the Department :

Letter No.*
Letter Date*
Designation*
Department*
Address*
Purpose of Certificate* Job on compassionate grounds Pension Ex gratia
Applicant’s Details :
Applicant’s Name* Relation With Deceased*
Father’s/ Husband’s Name* Date of Birth*
Gender* Male Female Transgender Aadhaar No
Mobile No* E-mail*
Applicant’s Address:
House No / Flat No * Sector / Village*
Tehsil / Sub-District* District*
State/UT* Pin Code*
Details of the Deceased :
Name of Deceased* Father’s/ Husband’s Name*
Gender* Male Female Transgender Single Married
Marital Status*
Date of Death* Widowed Divorced
Designation* Mother’s Status* Alive Deceased
Buddhism Hinduism Jainism Christianity Islam Sikhism
Religion*
Others (Please Specify) 
Address of the Deceased:
House No / Flat No * Sector / Village*
Tehsil / Sub-District* Chandigarh District* Chandigarh
State/UT* Chandigarh Pin Code* Chandigarh
Details of Dependents:
Relationship
Sr. Marital Income*
Name* with Age * Occupation*
No. Status* (per annum)
Deceased*
1
2
3
4
5
6
7
8
9
10
11
12
Self-Undertaking
I………………………………………………………………Son/Daughter of Sh. ……………………………………………………….. aged
………… resident of ……………………………………………………………………………………………., verify that the above
contents and supporting documents are correct to the best of my knowledge and belief and nothing has Photograph of the
been concealed therein. I am aware that in case the information furnished above is found to be person applying for
incorrect, I shall be liable for prosecution under Section 177 & 191 of the Indian Penal Code, which
the certificate with
stipulates imprisonment and fine.
cross signature)
Date : …………………………………………… Signature : ………………………………………………………………..

Place: …………………………………………… Name : ………………………………………………………………..

*Without cross signature (half on paper and half on photograph) and signature on undertaking the application will be rejected
 Check List of Requisite Document Required while Applying
(Please check against the document being provided while applying)
Applicant has to bring original documents for verification and scanning at Sampark

1 Application form along with Rs 2/- court fee (1.25 /-)

2 Photograph of Applicant
3 Identity Proof of Applicant
4 Self-undertaking/Affidavit
5 Letter from the Govt. Department addressed to DC Office regarding dependency
6 Death Certificate of Deceased employee in original
7 Residence proof of all the Dependents
8 Date of Birth proof of all the Dependents

Additional Document in Case the Purpose of Dependent Certificate is Pension

1. Income proof of son/daughter(s) of the deceased having age more than 25
2. Marital status proof of son/daughter(s) of the deceased having age more than 25

Date: ……………………………………….. Signature : ………………………………………………………………..

Name : ………………………………………………………………..

Undertaking from Sampark Operator

It is hereby certified that the original documents as specified in the above checklist have been personally seen by
me and the same have been uploaded in the online application

Date: ……………………………………….. Signature : ………………………………………………………………..

Name : ………………………………………………………………..

Documentary Proof of Address Documentary Proof of Identity Documentary Proof of Date of Birth
 Passport  Election Commission Photo ID card  Birth certificate issued by a Municipal
 Telephone (BSNL landline or post-paid mobile  Aadhaar Card / E-Aadhaar letter issued by Authority or any office authorized to issue
bill) on the Name of Applicant government of India. Birth and Death Certificate by the Registrar of
Births & Deaths
 Election Commission Photo ID card  Driving License
 School leaving certificate / Secondary School
 Applicant's current and valid ration card  Passport leaving certificate/ Certificate of Recognized
 Aadhaar Card / E-Aadhaar letter issued by  Arm’s License with Photo Graph Boards from the school last attended by the
government of India.  Central Government Health Scheme Card or applicant or any other recognized educational
 Registered Rent Agreement (for a period of Ex-servicemen Contributory Heath Scheme institution
more than one year) photo card  Passport
 Photo Passbook of running Bank Account  Applicant's current and valid ration card with  Affidavit sworn before a magistrate stating the
(Scheduled Public Sector Banks and Regional Photograph date of birth in case of illiterate and Semi-
Rural Banks only)  Photo identity card issued by the Central literate(Below Class 5)
 House Allotment Letter Government or a State Government or a  Pan Card
 Revenue Record Public Sector Undertaking

 Registered Sale Deed  Pensioner Card having photograph of the

applicants
 Certified Voter List
 Certificate of identity in original signed by
Member of Parliament or Member of
Legislative Assembly or a Gazetted Officer
containing duly attested photograph
 Bank certificate in original on letter head from
the branch (along with name and stamp of the
issuing officer) containing duly attested
photograph and bank account number of the
applicant(Scheduled Public Sector Banks and
Regional Rural Banks only)