Form No 3 Details of Family [ See Rule 54 (12) of CCS (Pension) Rules, 1972 ] Name of the Government Servant : Designation : Date of Birth : Date of Appointment

Form No 3 Details of Family [ See Rule 54 (12) of CCS (Pension) Rules, 1972 ] Name of the Government Servant : Designation : Date of Birth : Date of Appointment : Details of the members of my family *as on______________ S. No Name of the members of family* Date of Birth Relationship with the officer Initials of the Head of Office Remarks 1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 I hereby undertake to keep (Extractive summary — verify with official source.)