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Form-MED-DE
OIL AND NATURAL GAS CORPORATION LTD
APPLICATION FOR DECLARATION/RESTORATION OF DEPENDENCY
OF FAMILY MEMBERS
CPF No: Name:
Designation: Section/Site:
Org. Unit: Location:
Basic Pay: !s." PP: !s." S#.Pay: !s." D$: !s."
Date o% &oining On or 'e%ore: 01.0(.1)*+ On or a%ter:
0,.0(.1)*+
ONC
1. Detais o% Broters/sisters
S.No. Name Broter/sister Date o% 'irt Occ#ation
Monty 2ncome
01
0,
03
04
,. Detais o% #arents5 nmarrie6 sisters"5 minor 'roters" 7o are
7oy 6e#en6ent #on me an6
are #ermanenty resi6ing 7it me.
S.No. Name Se8M/F"
!eationsi# $ge
01
0,
03
04
09
3. ota monty/anna income o% #arents %rom a sorces ;!s.
4. $mont o% monty #ension 6ra7n 'y te #arents5 i% any- !s.
Contd.2/-
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9. Detais o% son/6agter 7ose 6e#en6ency is to 'e restore6:
Name $ge Marita
stats
!eason %or 7it6ra7a
o% 6e#en6ency
!eason %or restoration o%
6e#en6ency
(. e %oo7ing 6ocments are attace6 ere7it in s##ort o% my reer
isnot a##ica'e":
a. $ se%-6ecaration in te #rescri'e6 %ormat.
'. 2n case te #arents 6ra7 #ension %rom o>t./Semi o>t.
De#artment or PSU5 a #otoco#yo% #ension #ay or6er in6icating te
#ension amont 7itot commtation an6 a certi%icate
%rom te #ension 6is'rsement atority in6icating te crrent #ension
inc6ing a
com#onents.
c. 2% 'roters"/sisters" o% te em#oyee are em#oye65 a certi%icate
%rom teir em#oyer
certi%ying tat tey are not caiming any %aciity in res#ect o%
#arents %rom teir
6e#artment/organi?ation.
6. $ co#y o% etter acce#ting resignation %rom te ast em#oyer an6
a co#y o% #roo% o%a6mission to iger st6ies/corse in res#ect o% 7ar6
7ose 6e#en6ency is to 'e restore6.
e. $ co#y o% or6er isse6 'y te @onA'e Cort regar6ing
se#aration/6i>orce in res#ect o%
6i>orce6 6agter 7ose 6e#en6ency is to 'e restore6.
%. $ co#y o% 6eat certi%icate o% s'an6 in res#ect o% 7i6o7e6
6agter 7ose 6e#en6encyis to 'e restore6.
Date6: Signatre o% te Em#oyee
For se in @!/E!
Esta'isment O%%icer
De#en6ency acce#te6/restore6 in res#ect o% te %oo7ing %or
a>aiing o% te %aciity as in6icate6 againsteac:
Name o% 6e#en6ent !eation Faciity #ermitte6
a.'.
c.
6.
Signatre o% 2ncarge5 @!/E!
