SINGLE COMPREHENSIVE FORM

PLEASE FILL IN ALL THE ITEMS PROPERLY AND CAREFULLY, IN CASE A PARTICULAR ITEM IS NOT APPLICABLE, PLEASE STAE SO BUT DO NOT
LEAVE THE ITEM BLANK. THIS FORM NOT COMPLETED IN ALL RESPECTS WILL NOT BE ACCEPTED AND A FRESH SINGLE COMPREHENSIVE FOR
MAY BE CALLED FOR.
(As per memo No. 416-F(Pen) dt. 09/08/2019 of Govt. of West Bengal, Finance Deptt.)
1. a Name of the Govt. employee( IN BLOCK LETTERS) JHARNA DAS
b HRMS ID 1982005206
c PAN ADQPD4344K
d AADHAAR (Optional) 765833656572
Name of the establishment last served / serving with full Address BMOH, Biswanathpur BPHC, Deganga Block, PS-
e
including Pin code and Telephone No./ FAX No./ Mail Address Deganga, (N) 24 Pgs, Pin - 743423
f Designation of the Govt. employee Health Supervisor (Female)
g Employee Group (As per applicable ROPA) B
2 Date of Birth of Govt. employee(dd/mm/yyyy format) 12/06/1961
Nationality INDIAN Gender FEMALE
a
Religion (Optional) HINDUISM Blood Group B+
3
b Marital Status WIDOW
c Name of the Spouse / Father LATE RATAN DAS
4 Father's Name of the Govt.employee LATE AMULYA KUMAR MONDAL
5 Mother's name of the Govt. employee LATE HIRANMOYEE MONDAL
Class of Pension applicable
6 Retiring Pension
(Superannuation/Family/ Retiring/ Invalid/Pro rate etc) in this case
Whether a member of General Provident Fund (GPF) If
7 a YES
so, quote GPF Account No.
b If Yes, provide GPF Account No. MED/WB/36462
Address of the Govt. employee:
House No. / Bldg No.
Street/Road/Lane 3/31 ARABINDA NAGAR, PO-REGENT PARK
Area/Locality/Sector
a Present
Village/Town/City PS-JADAVPUR
District KOLKATA PIN CODE 700040
State WB POST OFFICE REGENT PARK
House No. / Bldg No.
Street/Road/Lane 3/31 ARABINDA NAGAR, PO-REGENT PARK
Area/Locality/Sector
b Permanent
Village/Town/City PS-JADAVPUR
8
District KOLKATA PIN CODE 700040
State WB POST OFFICE REGENT PARK
House No. / Bldg No.
Street/Road/Lane 3/31 ARABINDA NAGAR, PO-REGENT PARK
Area/Locality/Sector
c Communication
Village/Town/City PS-JADAVPUR
District KOLKATA PIN CODE 700040
State WB POST OFFICE REGENT PARK
d Mobile No, of Pensioner (For SMS alert & OTP) 9830459722
e E-mail id of the Pensioner (Optional)
a Name of the recipient of family pension (in BLOCK LETTERS) LIPIKA DAS
b Relationship with Govt. employee DIVORCE DAUGHTER
c Date of Birth (DD/MM/YYYY format) 26/06/1989
9
d AADHAAR (Optional)
e Religion (Optional) HINDUISM Gender Male / Female / Transgender
f Reason [In case 9 (a) above is not filled

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