ANDHRA PRADESH REVISED PENSION RULES, 1980 (As ... - APHB

APNDIX - IV
Form - C
Medical examination by the ...........................................................
(Here enter the medical authority)
Part - I
247
Statement to be filled in by the applicant for commutation of a portion
of his pension under Andhra Pradesh Civil Pensions (Commutation) Rules,
1944.
The applicant must complete this statement prior to his examination
by the .......................................................................................................
(Here enter the medical authority)
and must sign the declaration appended thereto in the presence of that
authority.
1. State your name in full
(in block letters)
2. State place of birth
3. State your age and date of birth
4. Furnish the following particulars concerning your family :
Father’s age Father’s age No. of brothers No. of brothers
if living and at death and living, their ages dead, their ages
State of health cause of death and state of health at and cause of
death
Mother’s age Mother’s age No. of sisters No. of sisters
if living and at death and living, their ages dead, their ages
State of health cause of death and state of health at and cause of
death