[See section 20 (8) and 26 (3)]

(1) Name of the individual : (2) Full Postal Address : (3) Details of job held, if any : (4) Particulars of her children, if any : (5) Name and last occupation of her late husband : (6) Date of demise of her husband : (7) Monetary benefits received after her husband’s death by way of family pension, insurance, etc., if any : (8. Details of Properties if any immovable and movable : left behind by him (9. Present monthly income.— (a) From salaries/wages : (b) From family pension : (c) From private properties : (d) Rents received : (e) From private practice : (f) Other sources, if any : (g) Total : 10. Whether living alone or living with her husband’s parents/in-laws/ parents/brother (s) : 11. Whether she satisfies the definition : of the term “Destitute Widow” as defined in section 20(8) and 26 of this Act Certified that I have verified the particulars furnished by the individual and satisfied myself as to the correctness of her claim with reference to the definition of the term “Destitute Widow” in section 20(8) and 26 of this Act Certificate Reference No.: Signature : Place: Name : Date: Designation : Revenue Divisional Officer/ Assistant Collector/Sub-Collector. Explanation- The above certificate should be issued only by the Revenue Divisional Officer or the Assistant Collector or the Sub-Collector concerned.