FORM 1
[See rules 5, 9 and 15(1)]
Form of application for purchase of Social Security Certificates

To

The Postmaster,

1. I, ……….son * / daughter * / wife * of…………………hereby apply for the purchase of Social Security Certificates as detailed below and tender the amount of their face value :

Form of tender	Amount tendered Rs.	Number	Certificates required Denomination	Total face value Rs.
1	2	3	4	5
(i) Cash
(ii) Cheque, demand draft or pay order
(iii) Application for withdrawal from post Office Savings Bank
(iv) Matured old certificate(s) for investment
Total :

Declarations :
2. I hereby declare-
(a) that I agree to abide by the Social Security Certificates Rules, 1982;
(b) that I am of good health (see paragraph 6 below);
(c) that I am not less than 18 years, and not more than 45 years of age and my date of birth is (day, month and year in Christian era) in evidence of which I attach the document specified at item………………..of paragraph 7 below together with a copy ** of that document;
(d) @ that I have not previously purchased any Social Security Certificate;
OR
(e) @ that the aggregate face value of certificates applied for in paragraph 1 above and the Social Security Certificates already purchased so far, detailed in paragraph 8 below does not exceed Rs. 5,000 and I agree that the certificates registered in other postal circles, if any, may be transferred to your office;
(f) that no proposal of insurance on my life has been rejected at any time by the Life Insurance Corporation of India or under the Postal Life Insurance Scheme.
*Cross out, if not applicable.
** Copy must be attested by a gazetted Government officer with date and seal of his office affixed.
@ Cross out (d) or (e), as the case may be.
Nomination :
3. $$ Under the provisions of section 6(1) of the Government Savings Certificates Act, 1959, I hereby nominate the person(s) mentioned below who shall on my death, become entitled to the certificate(s) purchased through this application and the amount due thereon to the exclusion of all other persons :

Details of nominees
Sl. No.	Name	Full Address	Date of birth, if nominee is a minor

 As the nominee(s) at Serial Nos. above is/ are minor(s), I appoint the following persons to receive the amount due on the said certificate(s) in the event of my death during the minority of the nominee(s).

Name of the nominee	Name and address of person appointed

Witness :	Signature of witness

 Name :
 Address:
 4. $ I require identity slip.
 5. # The certificate(s) (and identity slip $) may be made over to Shri/Smt………… agent (Authority No. ……………………) or to my messenger Shri/Smt …………….presenting this application.
 Declaration of health :
 6. I hereby declare-
(a) that I am of good health,
(b) that during the last three years I have not suffered from asthma, pneumonia, spitting of blood, tuberculosis, high or low blood pressure, rheumatic fever, diabetes, jaundice, any disease of kidney, prostrate or urinary system, paralysis, insanity, epilepsy, fits of any kind or nervous breakdown or any other disease of the brain or nervous system, cancer, leprosy, rheumatism, tumour or veneral disease, and
(c) that I have not undergone any surgical operation which has resulted in my hospitalisation for more than ten days during the last three years.

Full address of applicant	Signature (or thumb impression if illiterate) of applicant
	Date

$$ Cross out paragraph 3, if nomination is not required.
$ Cross out, if identity slip is not required. For identity slip, if required, applicant’s specimen signature and marks of identification must be furnished in the space below paragraph 8.
# Cross out, if the certificates and identity slip (where required) are to be received by the applicant personally.
 Evidence of date of birth :
 7. Original document to be returned to the applicant :
 (i) Certificate of birth issued by local authority………………..(name of Municipal Corporation, Municipality, Panchayat or other body concerned).
 (ii) Matriculation certificate or equivalent, namely……………………(to be specified).
 (iii) Certificate issued by………………….(name and address of the school, college or other educational institution attended by the applicant)
 (iv) Certificate of baptism issued by (name and address of the issuing authority)-

(v) Receipt for life insurance premium	Issued to the applicant by
(vi) Life Insurance Policy	LIC or PLI authorities.

 (vii) Letter issued to the applicant by the LIC/Postal Life Insurance authorities stating his date of birth as accepted by them.
Not to be returned to the applicant.
 (viii)True copy/extract of the applicant's service record kept by his employer (name and address of the employer) stating the applicant's date of birth as accepted by the employer; alongwith a letter/ certificate in original from the employer stating that he has accepted the said date of birth on the basis of standard proof.
 8. Social Security Certificates previously purchased by the applicant and not matured or prematurely discharged as on the date of this application :

SI. No.	Certificate number and date	Face value (Rs.)	Name of Post Office where registered
1	2	3	4

 For identity slip
 Marks of identification of applicant.
(i) …………………..Speciman signature of applicant
(ii)
RECEIPT OF CERTIFICATE(S)
 Received the certificate(s) detailed at paragraph 1 above and * identity slip.

	Signature or thumb impression of applicant or his messenger/Agent (Authority No )
	Date

 * Cross out if not required.
FOR USE OF POST OFFICE
 Age group of applicant at the time of application :

A	18-30 years	C	36-40 years
B	31-35 years	D	41-45 years

 Total number of certificates issued as follows with reference to paragraph 1 :

Certificate number	Issue price (Rs.)	Date of encashment	Initial of Postmaster	Remarks (transfer issue of duplicate, etc.)

 Identifier of applicant **
 Action for transfer of certificates from other circles

Date	Signature of Postmaster

** Name and address of identifier to be given, if the applicant is not known to the postmaster.