LIST OF FAMILY MEMBERS OF LATE ____________________________________

S/O

____________________________________________EX

__________________________@
___________________________________________________________________________
_______________________________________________ PPO NO. ___________________

S.No

Name of Family
Member

Date of
Birth

Marital
Status

Relationship
with Deceased
Employee

Mother
Name

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

CERTIFICATE
It is certified that there is no any other family member except shown as above.

Attested by:
Signature______________________
Name_________________________
CNIC No.______________________
Address_______________________

COUNTERSIGNED

CERTIFICATE
Certified that Mst. ________________________________________ Wd/o
Late ___________________________________________ has not judicial separation during
lifetime of her husband Late Mr.________________________________________________

Attested by:

Signature______________________
Mst.__________________________
Wd/o _________________________

Specimen Signature of Mst. __________________________________________________

Wd/o Late Mr. ___________________________________________________________

1.

____________________________

2. ____________________________
3. ____________________________

Attested by:

Thumb and Finger Impressions of Right Hand in respect of Mst. __________________

Wd/o __________________________________________________________________

Thumb

Forth Finger

Middle Finger

Ring Finger

Little Finger

NO MARRIAGE CERTIFICATE
I, Mst. _________________________________________________________
Wd/o

___________________________________________________________,

having

CNIC No. ____________________________________ do hereby solemnly declare that I

have not remarried after the death of my husband Late Mr. __________________________

Attested by:
Signature______________________
Mst.__________________________
Wd/o _________________________

NO MARRIAGE CERTIFICATE
I, Mst. _________________________________________________________
Wd/o

___________________________________________________________,

having

CNIC No. ____________________________________ do hereby solemnly declare that I

have not remarried after the death of my husband Late Mr. __________________________

Attested by:
Signature______________________
Mst.__________________________
Wd/o _________________________