The Mandal Revenue Officer,
.................................Mandal.
Sir,	 
    Sub: 	Application for issue of  Legal  Heir Certificate/Family Member 		Certificate  - Requested - Regarding.
I beg to submit that my ...................... R/o H.No.......................expired on........... 
He/She was a Pensioner
He/She has expired while in service working as a .................................................
...................................... in the office of the .........................................................
I have applied for Legal Heirship Certificate/Family Membership Certificate to submit the same at  ..................................... for getting to claiming  pensioner benefits Life-time ............................ arrears appointment ....................of  ..........................my
Smt/Kum/Sri ............................................................................................
NAME OF THE FAMILY MEMBERS ARE GIVEN BELOW:
Sl.	Name of the family	Age	Relationship with     Marital
No	         member	.		the Deceased             Status
1. ........................................................................................................................
2. ........................................................................................................................
..
..
12. ......................................................................................................................
I therefore, humbly request your goodself to issue me the Legal Heirship Certificate/Family Membership Certificate. The Death Certificate Sl.No. ................................ Dated .....................  and pension payment slip/service certificate of his/her deceased  are submitted herewith for your kind perusal and necessary action.
	Thanking you,		Yours faithfully,				Date:				Name: ........................................................
Address ...................................	(IN BLOCK LETTERS)
	W/o. D/o. S/o.  ............................................
SWORN STATEMENT OF ................ S/o ..................Aged about (   ) years, working as a ..........R/o. H.No......... recorded on .............................. I,............................... do hereby solemnly affirm and state   on oath that, I am well acquainted with the facts of the case and I know personally the Late .......... R/o .....................He / She was working as .............. and he/she expired while in service/after retirement on  .....................................leaving behind the following Legal Heirs/FamilyMembers.
Sl.   	Name of the family        Age        Relationship with	Station	
No. 	member 			       The Deceased.	
1. ........................................................................................................................
2. ........................................................................................................................
..
..
12. ...........................................................................................................
Except the above (        ) members, there are no other Legal Heirs to the deceased  Shri / Smt. ................. is the only wife of  the  deceased.  The deceased had not married twice during his/her life time. The above facts are true and correct to the best of my knowledge and belief and  I am totally responsible for the same.   Recorded and  explained to me in my mother tongue .................................................and submitted by me to be correct.
\"RECORDED BY ME"            
DR.I. (                  ) Circle