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 lifetime. 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   		
Deponent

REPORT OF REVENUE INSPECTOR .....................CIRCLE
To						Date: ............................
The Mandal Revenue Officer,
.................................. Mandal,
Sir
Sub: ISSUE OF L.H.C/F.M.C. A/c..................
 S/o. ............................................ R/o. ................................Ref:  Endt. of the MRO/P.T/SUPDT, Dated ...........................A/c ........................... In continuance to the endorsement cited I had been to be  locality  during the enquiry.
It reveals that applicant's Husband/Wife/Mother/Father, Sri/Smt. ..........................S/o. W/o. ..................................R/o. H.No. ...................... in the office of the ...................... has expired on ....................................  at ..........................................................   leaving   behind  the following Legal Heirs/Family Members of the deceased. He is issueless/bachelor.
Sl.	Name of the	Age		Relationship with          Marital
No.	family member			the Deceased.	          Status.
1. ........................................................................................................................
2. ........................................................................................................................
..
..
12. ......................................................................................................................
Except the above there are no other Legal Heirs/Family Members of the deceased and he has married only one wife/two wives in his life time. Legal Heirs/Family Members Certificate is required for the purpose of pension and other benefits, the original papers are returned herewith also with sworn statement of a Govt. Servant who knows well about Legal Heir/Family Members particulars of the deceased.	
						Yours faifhfully,
 REVENUE INSPECTOR --------CIRCLE

GOVERNMENT OF ANDHRA PRADESH
(REVENUE DEPARTMENT)
Office of the      	
Mandal Revenue Officer,
...............................Mandal

No. ……………………					   Date  : ................................

LEGAL  HEIR  CERTIFICATE
The Mandal Revenue Girdawar Inspector, .......................................Mandal, vide No...................Date : ............. . It is to certify that Smt. & Sri ................... S/o.W/o.Sri  R/o..........a pensioner/  while in service expired on ................The following are the heirs of the deceased.
Sl.	Name		Age     Relationship with                  Marital
No.                                                           				the Deceased.                		    Status
1. ........................................................................................................................
2. ........................................................................................................................
..
..
12. ......................................................................................................................
This certificate is issued only to draw the pension of the deceased and to claim any other benefits of his Service, but not for other purposes.

MANDAL REVENUE OFFICER

………………………MANDAL