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No.
FORM MOAP -I

APPLICATION FOR OLD AGE PENSION
(MANIPUR)
1. Name of Applicant :
   (Full Name in Block letter)

2. Identity card No. in case of old pensioners :

3. Age (Age proof certificate from any medical officer) :

4. Marks of identification :

5. Name of father/ husband :

6. Present address :

7. Permanent address :

8. Address where the applicant has resided for a
   period exceeding 10 (ten) years. :

9.Is the father/husband/wife alive :

10. How have you been maintaining yourself so far :

11. Whether disabled? If so permanently or partially
      disabled? (Name/nature of disability which
      has incapacitated (him/her to earn livelihood). :

12. Particulars of dependant :-

    No.      Name                                    Age                               Relationship


13. Particulars of :
a. Earning son (s) / Grand son (s) or daughter (s)/ :
Husband/Wife/ Daughter (s) indicating their name,
address and monthly income and also their own 
family liabilities, if any, (specify whether they are
staying with or seperately from the applicant
giving the name and age of their dependents, if any).

14. Applicant’s educational qualifications :

15. Occupation/profession of the applicant before he/she :
      become infirm or unfit to earn and monthly income.

16. Whether in receipt of any loan or grant or pension or : 
      gratuity or any other assistance from Govt. If so,
      indicate the amount.

17. Particulars of properly held :

(a) Movable (indicating probable value) :
(b) Immovable with details and approximate value. :
(c) Bank Balance or deposits in Post Office saving Bank. :
(d) Investments in Government Securities. :
(e) Income from any other source (s). :

18. Whether belongs ti Schedule Caste/Tribe/Backward :
     Classes or not ? If reply is in the affirmative, which 
     caste/tribe Community (Attach Certificate). 

19. Name and address of two responsible persons well-known :
     to the applicant who could certify the correctness of 
     his/her statement.

1. … … …. …. …. …. …. …. …. …. …. ….
2…. … …. … …. …. …. …. …. ….. …. ….


Date … …. …. ….                                          Signature /Thump-impression of the applicant. 
    

DECLARATION

I ………………………………………………………………………. son of/wife/d/o.............. ……………………………………………………..resident of ………………………………
………………….. Post office ……………………………….. of ………………………………
District ………………………………… hereby solemnly declare and affirm that to the best of my knowledge and belief nothing has been concealed.


Attested by a Gazetted Officer.                          Signature /Thump-impression of the applicant.



                        RECOMMENDATIONS OF THE DISTRICT SOCIAL WELFARE
                                      OFFICER OF THE DISTRICT CONCERNED.

                        

                                          Signature with Office seal of the 
                                          recommending authority.
  

INCOME CERTIFICATE

This certificate is to be signed by DC/SDO/SDC or an employer in case of
an employed Applicant/Husband/Wife/Son(s)/Daughter(s)/
Grand Son(s)/ Grand Daughter (s).
  
Certified that to the best of my knowledge the annual income from all sources in the preceding years ending 31st. March of the Applicant/Husband/Wife/Son(s)/Daughter(s)/ Grand Son(s)/ Grand Daughter (s) are as follows :-

Total income of

1. Applicant :

Shri/Smt. ………………………………………………………………. son/daughter/husband/
wife of ………………………………………………………………… age …………………
is Rs. ………………………..( Rupees ……………………………………….) only.

2. Husband/Wife :

Shri/Smt. ………………………………………………………………. son/daughter/husband/
wife of ………………………………………………………………… age …………………….
is Rs. ………………………..( Rupees ……………………………………….) only.

3. Son(s) :

          1. Shri ………………………………………………………………….. Single/Married
age…………………………. is Rs. ………………………….( Rupees ………………………..) only.
         2. Shri ……………………………………………………………………… Single/Married
age…………………………. is Rs. ……………………( Rupees ………………………..) only.
         3. Shri …………………………………………………………………….. Single/Married
age…………………………. is Rs. …………………….( Rupees ………………………..) only.
        4. Shri ……………………………………………………………………... Single/Married
age…………………………. is Rs. ………………………….( Rupees ……………….) only.

4. Daughter (s) :

         1. Smt. ……………………………………………………………………… Single/Married
age…………………………. is Rs. ………………………….( Rupees …………………..) only.
        2. Smt. …………………………………………………………………….. Single/Married
age…………………………. is Rs. ………………………….( Rupees ………………..) only.

Date ……………………….

 

Signature with official seal.

 
 

 

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