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86 Éæ¾ø ïÀåó ¡å¨îºø ÀºòÆ

̹Ç× 86
General 86
*
(A4 S., T & E.) 9/69
(Internet Version)

Éæ¾à¼Åê Íå ¡¾ºà¼Çæ —ÊòåÄ Éæ´êÀà ¨òÄÆ

Œ¶ÎÁ¯¿Æ, £·Çζ¯¿Æ §¹¯Ç¼±Æ ±ºÆ¹¿¶Æ¶È´Æ´ºÆ
WIDOWS’ AND ORPHANS’ PENSION SCHEME

Éæ¾à¼Åê Íå ¡¾ºà¼Çæ —ÊòåÄ Éæ´êÀà ¡ÇÄê¼È ÀèÎÂ

è ¿ ¡å³åÀ¾º (431 ÀփïؼÆ) 21 Éæ¾ø ɪ¾àºÆ
ø
Æ´ïºà ¨Ç¾ Àò¨åÊÆÆú
Œ° £° §° ·È¶È¯Æ ¯´Æ´Î¿±Æ ±´Æ´¶Æ¶È 21 ¤ºÆ ‰ÇȌ¹ˆ ̱»ÆÜºÆ ‰¼¯´¸ºÆ (£¶Æ¶È»Ç»ºÆ 431)
DECLARATION UNDER SECTION 21 OF THE W. & O.P. FUND ORDINANCE (Cap.431)

¾øȽåÖÆåïªà ̊ÀìÚ¸ ¾Ä
£ßÁ¾Çȁ Ûá¹Æ̹»ÇÆ (¶¸È¹Æ ͹̼á¶ÆׯƯ¿È¾Æ) ..................................................................................................................................
Full Name of Officer (Block letters)

º¾ºëÇ ÌŠÀìÚ¸ïƾà ï¼ÀåںàºëÉ

Ûá¹Æ ¹¶Œ¹Æ̹»ÇÆ ........................................................... £¼±Ç+Ư¶Æ ¶Èε¯Æ¯¿ºÆ ............................................................
Designation in Full Department

Éæ¾à¼Åê Íå —ÊòåÄ Éæ´êÀà ¡ÇÄê¼È´ Âæ߸ê

¼ú¾Æ Íå ¦¼ú¾´ ÈæÂì ÉåÚËè¨ Éæ´êÀ ÉÚËƨ´ ÇæÀèÆÈà .........................................................
Œ° £° §° ¶È´Æ´¶Æ¶È½Æ ͱÇƷƶ Ͷ¶ÈÜºÆ ................................................ ô¹Ç ............................................................................................ ¤®Õ¯ÆÐ
£¶ÆͶ¶ÈŠ½Æ ̹½Æ½ ¤®Õ±Æ ±ºÆ¹¿ÛºÆ
Date of joining the W. &. O.P. Scheme and Rs. ................................................................................................ per annum
annual salary at such date

(i) ¾ùºøïÆ¾à ¾øȽåÖÆå´ ÂÈÆ ÈæŸ ¡æºàïºà ï¨åÆú ÀòÌàºåÉƨ¼û

ÉêÉºà ¦¨à ÃåÆñþåɨà Àĸ¨à ¡åǨàËå ¨ø×Ä´ ¼ ƾ ɪ .................................................................................
¥ÁÆÁßÁ¾ÇÆ ±´Æ´¹Æ¹ˆ ¬Ý ºÎ¸ŒÎ» ºÇ¶Æ¶È¼ºÆ ¬Í¼ ¯Ç¾¶Æ¶È¾Æ
ŒÁǯ³Æ̱»Æ» §ÇȶÆ×δ»Á¼ÇÌÁ¸¯Æ çÞ¯
State whether the officer is by law entitled to have only one wife .................................................................................
at any one time

Éæ¾à¼Åê Íå ¡¾ºà¼Çæ —ÊòåÄ Éæ´êÀà ¡ÇÄê¼È ÀèÎè¿ ¡å³åÀ¾ïºà 431 ÀփïؼïÆà 21 Éæ¾ø ɪ¾àºøÆ Æ´ïºà ÌæÀÆúÆ Æêºë Àͺ ̿;à
—ÌàºÇ ÌæÂç ÂÉºà ¾øÉæǼú ÂÉºà ¦à ¡å³åÀ¾ïº¾à ¤Àê´å諭 ïÄÍú ¡¾ø¨à Àèï… Ì¿Í¾à (21 Ìè´ 26 ¼¨àÉå Éì) ïÌÌê ɪ¾àºø Íå ïÄÍú Àͺ
¼æ¨àïɾ ÌâȨàËñÆ¾à ¨øÆÉì Âɺà ............................................................................................................................................................. ɾ ÄÄ
ïÄÆú¾à Àò¨åÊ ¨Ç•. Éæ¾à¼Åê Íå ¡¾ºà¼Çæ —ÊòåÄ Éæ´êÀà ¡ÇÄê¼È ÀèÎè¿ ¡å³åÀ¾ïºà 16 Éæ¾ø ɪ¾àºøÆ Æ´ïºà Àò¨åÊƨà Äå —Ìè¾à ä´ ¨Èè¾à
ï¾å¨Ç¾ ȼû.

°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° ¤¯È» ·Ç Œ°£°§° ·È¶È¯Æ ¯´Æ´Î¿±Æ ±´Æ´¶Æ¶È

(£¶Æ¶È»Ç»ºÆ 431) 2 ¤ºÆ ‰ÇȌ¹ˆ ÌÁ¿È¹Æ¹Õ¶Æ×ºÆ Œ¹¼+Ư¿Æ §®Îº»Ç¸ÎÁÌ»ÞºÆ ±ÇȻǸÎÁÌ»ÞºÆ ºÞ¹¯Æ¯¶Æ¶Èß¿Æ¿ º½ÆÞºÆ
(21 Û¶¾Æ 26 Áμܿƿ) ‰ÇÈâ¯Î¿ÜºÆ £ˆ¯ÆнȹÆÚ¯Î¿ÜºÆ ÁDZȶÆ׿ÆÍ¿Ì¸ÞºÆ ¥¶Æ¶Ç¾Æ ÌÁ¿È¹Æ¹Õ¶Æׯȁͽ° ¥¶½ÆÐ ò Œ°£°§
·È¶È¯Æ¯´Æ´Î¿±Æ ±´Æ´¶Æ¶È¹ˆ ¥ÁÆÁί¹Æ ‰¼¯´¸¶Æζ ·Ç ̯ÇկƯŒ¾Æξ°

I, ............................................................................................................................................................................................ hereby declare

that the undermentioned particulars required under Section 21 of the W. & O.P.Fund Ordinance, Cap. 431 are true and correct and that I have read
the extracts of the other Sections (21 to 26) of the Ordinance and the notes below. No declaration under Section 21 of the W. &. O.P. Fund Ordinance
(Cap.431) has been furnished by me previously.

H - 022255 (2004/10) Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåںàºëÉ

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(¤) ¼ú¨à¨Ìå¼ Éì/
•ÆªúÆ ¼ú¾Æ
̊ÀìÚ¸ ¾Ä (¡) ¤À¾à¼ú¾Æ (¢) —ÉåÍ Éì ¼ú¾Æ (§) ŒÁǯ¼¶Æ×¶Æ ¶È¯¶È/
Ûá¹Æ̹»ÇÆ (¶¸È¹Æ ͹̼á¶ÆׯƯ¿È¾Æ) (£) ‰½·Æ¶ ¶È¯¶È (¤) ŒÁǯ³Æ̱»Æ¶ ¶È¯¶È
º¼µºÆ
Full Name (Block letters) (a) Date of Birth (b) Date of Marriage
(c) Date of
Divorce/ Death

¾øȽåÖÆå ................................................................................................................................................................................................
£ßÁ¾ÇÆ
OFFICER ................................................................................................................................................................................................

(¦) ÃåÆñþåÉ ................................................................................................................................................................................................

(©) ºÎ¸Œ
(d) WIFE ................................................................................................................................................................................................

(§) Õɺà É Ìè  ¾ ÎÄÆú ¾ à ï ªà ¾Š –

¡Éê. 21 ´ ¡¶ê Àè֕ ÎÄÆú Íå ¡ÉêÇæó
21 ¨´ ¡¶ê ¡—Éåͨ ªæÍæ¸ê ÎÄÆú
Ìàºéò
(¬) §ŠÇÆ ‰ÎÀ¶Æ¶ÈݯÆÐºÆ ‰¿Æο¯¿Æ – ÀêÇæË
21 Á»×¯Æ Ð ´Æ ¹ ´Æ ´ ‰¿Æ Î ¿¯àºÆ , ÃåÉÆ
ŒÁǯºÇ¯Ç¶×ºÆ 24 Á»×¯ÆÐ۴ƹ´Æ´ ¤µÇ
̹® ‰¿Æο¯àºÆ° ̹®µÇ
Sex
(e) Names of surviving Children – boys
under 21 years and girls under 21 years
of age and Unmarried.

1. ...........................................................................................................................................................................................................................

2. ...........................................................................................................................................................................................................................

3. ...........................................................................................................................................................................................................................

4. ...........................................................................................................................................................................................................................

5. ...........................................................................................................................................................................................................................

6. ...........................................................................................................................................................................................................................

.........................................................
Àò¨åʨÆåïªà ¡ºà̾
‰¼¯´¸³Æ̱»Æ¹ÁÇÆ Î¯Ì»Ç¹Æ¹ºÆ
Signature of Declarant.

20 ........................................................... ÄÌ ...................... Éæ¾ø¼å ɾ

ïļú¾ Äå ¢¼úÖÀè´ ¼û .................................................... Àò¨åÊ ¨Ç¾ ȼû.
¥·Æ¶ 20 .............. ¤ºÆ ¤®Õ ...................................... ºÇ¶ºÆ ¤·Æ
...................... ·Ç¿Þ ............................................................ ¾Æ © ہÚ
‰¼¯´¸³Æ ̱»Æ»¹Æ¹´Æ´×°

Declared before me at ............................................................................

this .................... day of .................................................................20..........

............................................................................ .........................................................
Ìͺø¨ ¨Ç¾à¾åïªà ¾Ä ÌÍ º¾ºëÇ* Ìͺø¨ ¨Ç¾à¾åïªà ¡ºà̾
£¶Æ¶Ç´Æ±È¹Æ¹Õ¶Æ×¹ÁÇÆ Î¯Ì»Ç¹Æ¹ÛºÆ ¹¶ŒÜºÆ* £¶Æ¶Ç´Æ±È¹Æ¹Õ¶Æ×¹ÁÇÆ Î¯Ì»Ç¹Æ¹ºÆ
Name and Designation of Attestor* Signature of Attestor
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Éæ¾à¼Åê Íå ¡¾ºà¼Çæ —ÊòåÄ Éæ´êÀà ¨åÆñþåÈïÆà Äïªà ¡â¨Æ
ïÈਊ Íå ª¸¨å“¨åÖ ïɺ´Æú, ©¸× ¥¾° .................................
̱»¾Ç¿ÝºÆ ¯µ¯Æ¯Ç¿ÝºÆ, Œ° £° §° £ßÁ¾¯ºÆ, My No.
THE SECRETARY & ACCOUNTANT, W. & O. P. OFFICE

¢¼úÖÀºà ¨Ç• :
.......................................................................................................... ¾Äæºø ¾øȽåÖÆåïªà ¤À¾à ¼ú¾Æ §Íêïªà ¤ÀàÀæ¾à¾ Ìͺø¨Æ/ ¼úÉêÇæŠ
ïÀºàÌÄ (¨) Íå ÌÄ­ ÌÌ¿å ÂȾ ȼú¾à ¦à ¼ú¾Æ ¾èÉæǼú ÂæŒ ÄÄ Àò¨åÊ ¨Ç•.
.................................................... ¼å À´¾à ïŠ ¾øȽåÖÆå´ Éæ¾à¼Åê Íå ¡¾ºà ¼Çæ —ÊòåÄ Éæ´êÀà ¨òÄÆ´ Âæ¿ûÄ´ ÂÈÆ ºøï‰. ¦¼ú¾´ §Íêïªà ÉåÚËè¨
Éæ´êÀ .................................................... ¨ø.
ïÄÄ Àò¨åÊ¾Æ ÌçÄ ¡ÆêÖ¾àÄ ÌŠÀìÚ¸Æ.
£Ù¹Æ¹¹Æ¹´¾ÇŠ½ÆÞ° ͺ; (£) ¹·Æ¶ÈŠ½Æ ¶¼¹Æ¹´Æ´ §¶Æ¶Èͻǯ¶Æ¶Çȁ ‰½·Æ¶ Ͷ¶È £¶ÇÁ× ..............................................................

.................................................................................... £ÁÇȁ ‰½¹ÆÚ¹Æ ¹¶Æ¶È¼¶Æ×´/ ±¶Æ¶È»¯Æ ¯´¶Ç±ÈÜ´/ (¨) ¬¹Æ‰´ÆÕ¹Æ ¹ÇÇƯƯ¹Æ¹´ÆÕ

£× ¶Èε¯Æ¯¿¹Æ ¹¶Èâ¯Æ¯à´ ¬¶Æ¶ÈݯƯȁ½Ì¶ÞºÆ ·Ç £¶Æ¶Ç´Æ±È¹Æ¹Õ¶Æׯȁͽ° нȶƶ §¶Æ¶Èͻǯ¶Æ¶ÇÆ Œ° £° §° ¶È´Æ´¶Æ¶È¾Æ

.................................................................................... ©½ Ͷ¶ÈŠ¾ÈÝ·Æ×ͱÇÆ·Æ×̯ǿƿ §ÇÈκÜδ»Á̼ÞºÆ £¶ÆͶ¶È»È¾Æ £ÁÇȁ ¤®Õ±Æ

±ºÆ¹¿ºÆ ͺ; нȯƯ¹Æ¹´Æ´× Í¹Ç¾Æ ô¹Ç ............................................. ©ÞºÆ £½ÈŒ¯Æ¯ÈÍ½°

¥·Æ¶¹Æ ‰¼¯´¸ºÆ ©¾Æ¾ÇÁίŠßºÆ Ú[¼µºÇ¸×°

Forwarded :

I certify that the date of birth of the officer given in column (a) above viz ............................................................................... has been
checked with his certificate of birth/ affidavit (f) and it agrees with the departmental records. The officer is entitled to join the W. & O. P. Scheme
with effect from ........................................................................................................................................... and his annual salary on that date was

Rs................................................................... as stated above.

This declaration is complete in all respects.

.........................................................
¼ú¾Æ ï¼Àåںàºë Àò½å¾èÆå.
Ͷ¶È .................................
¶Èε¯Æ¯¿¶Æ ¶Î¾ÁÇÆ°
Date
Head of Department

¨åÚÆåÈïÆà ÀòïÆåà°¾Æ Ì¿Íå ÀĸÆú

£ßÁ¾¯¯Æ ¯Ýº+Ưà¯ÆÐ ºÇ¶Æ¶È¼ºÆ
For Office Use Only

ÈèÆåÀ¼ú⎠¨Î Éæ.¡.—.Éæ. ¡â¨Æ ¡â¨Æ ¼¾àɾ ȼàï¼à

Œ° £° §° ¹¶Èâ ¥¾¯Æ¯ºÆ .................................................. ¥¾¯Æ¯ºÆ £½ÈŒ¶Æ¶ÁÇÆ Ì¹»ÇÆ ..................................................
W. & O. P. Registered No. Number notified by

ªú¸êŠÀº Àè´Àºà ¨Ç¾ ȼàï¼à ¼ú¾Æ

¯µ¯ÆÐ £´Æδ ‰¼¶È ̱»Æ¶ÁÇÆ .................................................. Ͷ¶È .................................
Account Card copied by Date

¼ú¾Æ ÀרàËå ¨Ç¾ ȼàï¼à

Ͷ¶È ................................. ±ÇȉÎÀ ¹ÇÇƶƶÁÇÆ ..................................................
Date Checked by

¼ú¾Æ
Ͷ¶È .................................
Date

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è ¿ ÈèÀè ïÈ੾ ïÌåÆ媺 ï¾åÍæ¨ø Éì —´) Àĸ¨à
¼úÉêÇæŠ ïÀºàÌĨà ÃåǪ¾ê Èæï‰.
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—ÉåÍÆ ÈèÆåÀ¼ú⎠¨ïÎà ¾Š, ¦Æ ÈèÆåÀ¼ú⎠¨Î Ìͺø¨Æ ¦—Æ ÆêºëïŒ. ¤¶Ç´ —ÉåÍ ïɾêïɾà, —ÉåÍÆ ÈèÆåÀ¼ú⎠¨Î Ìͺø¨ÆÄ
¢¼èÖÀºà ¨ø×Ä ¡ºñåÉÊñÆ.
(¡æ) ¼ú¨à¨Ìå¼Æ¨à ̊¾à½ïƾà Éì —´, ¦à ÂÉ Ì´Í¾à ï¨å´ ¼ú¨à¨Ìå¼Æ ÀèÎè¿ ¾¶ê ºé¾àóïŒ Ìͺø¨ ¨Î Àè´Àº¨à ä´ ¡æ•¸èÆ ÆêºëÆ.
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(a) The date of birth of wife must be supported by a certificate of her birth. In very exceptional cases (i.e.- where the birth has not been registered
or registered but not traceable) an affidavit will be accepted. The affidavit which need not be stamped should be signed by the wife if living.
(b) If the officer is unmarried the word ‘Bachelor’ should be entered in this column. In the case of Hindu marriages the date of registration of
marriage according to Hindu rites and custom whichever is earlier, should be indicated with corresponding note. In the case of Kandyan
marriages only duly registered marriages will be recognised.
(c) Delete inapplicable word in case of divorce the date on which the decree was made absolute should be entered and a certified copy of the decree
of divorce should be attached.

(d) If the officer previously married, full particulars of such marriages should also be stated.

(e) If the officer has children by previous marriages full particulars of such children should be stated, the children by previous marriages being
clearly indicated by notes made against their names. In the case of children born to the officer by the wife prior to the registration of his
marriage a note to that effect should be made against the names of such children supported by their birth certificates. If any delay is anticipated
in obtaining these birth certificates they may be forwarded later.

(f) Delete what is not applicable. In very exceptional cases (e.g. where the birth has not been registered or registered but not traceable) an affidavit
should be accepted.

* This declaration may be made before a Civil List Officer, Justice of the Peace, Commissioner for Oaths, Notary Public Divisional Revenue Officer,
President of a Village Tribunal or an Inspector of Schools.

Note .– If the officer was previously employed under Government, full particulars of such employment should be noted overloaf. If the wife
has been previously married full particulars of such marriage and names and dates of birth of children, if any should be stated overleaf.