FORM 1
[See Rule 53(1)]

Nomination for Retirement Gratuity/Death Gratuity

   When the Government servant has a family and wishes to nominate one member, or more than one member, thereof.

    I,......................., hereby nominate the person/persons mentioned below who is/are member(s) of my family, and confer on him/them the right to receive, to the extent specified below, any gratuity the payment of which may be authorised by the Central  Government in the event of my death while in service and the right to receive on my death, to the extent specified below, any gratuity which having become admissible to me on retirement may remain unpaid at my death -

Original nominee(s) Alternate nominee(s)


Names
and
addresses
of
nominee/ nominees

Relationship
with the Government servant



Age

Amount
or share
of gratuity
payable
to each*		 Name, address relationship and age of the person or persons, if any, to whom the right conferred on the nominee shall pass in the event of the nominee pre-deceasing the Government servant or the nominee dying after the death of the Government servant but before receiving payment of gratuity

Amount
or share
of gratuity
payable
to each**
(1) (2) (3) (4) (5) (6)
 

 

          

This nomination supersedes the nomination made by me earlier on ....................................... which stands cancelled.

NOTE. - (i) The Government servant shall draw lines across the blank space below the last entry to prevent the insertion of any name after he has signed.
(ii) Strike out which is not applicable.

Dated this...................................day
of..................................................2000
at...........................................

Witnesses to signature :

1.
..........................................
2. .......................................... Signature of Government servant

*This column should be filled in so as to cover the whole amount of the gratuity.
**The amount/share of the gratuity shown in this column should cover the whole amount/share payable to the original nominee(s).

(To be filled by the Head of Office)

Nomination by..................................... Signature of Head of Office
Designation.......................................... Date................................................
Office.................................................. Designation.....................................

 

 

 

 

 

 

 

 

 

 

 

Pro forma for acknowledging the receipt of the
nomination form by the Head of Office

To

    ...................................................
    ...................................................
    ...................................................

Sir,

    In acknowledging the receipt of your nomination, dated the ................/cancellation, dated the ...............................of the nomination made earlier in respect of gratuity in Form ................................... I am to state that it has been duly placed on record.

Signature of Head of Office
Place ...........................................
Dated the .................................... Designation.............................................

    NOTE. - The Government servant is advised that it would be in the interest of his nominees if copies of the nominations and the related notices and acknowledgements are kept in safe custody so that they may come into the possession of the beneficiaries in the event of his death.

 

 

 

 

 

 

 

 

 

 

 

FORM 2
[See Rule 53(1)]

Nomination for Retirement Gratuity/Death Gratuity

   When the Government servant has no family and wishes to nominate one person or more than one person

    I,...................., having no family, hereby nominate the person/persons mentioned below and confer on him/them the right to receive, to the extent specified below, any gratuity the payment of which may be authorised by the Central Government in the event of my death while in service and the right to receive on my death, to the extent specified below, any gratuity, which having become admissible to me on retirement may remain unpaid at my death :

Original nominee(s) Alternate nominee(s)


Names
and
addresses
of
nominee/ nominees

Relationship
with the Government servant



Age

Amount
or share
of gratuity
payable
to each*		 Name, address relationship and age of the person or persons, if any, to whom the right conferred on the nominee shall pass in the event of the nominee pre-deceasing the Government servant or the nominee dying after the death of the Government servant but before receiving payment of gratuity

Amount
or share
of gratuity
payable
to each**
(1) (2) (3) (4) (5) (6)
 

 

          

    This nomination supersedes the nomination made by me earlier on .......................................which stands concelled.

NOTE. - (i) The Government servant shall draw lines across the blank space below the last entry to prevent the insertion of any name after he has signed.
(ii) Strike out which is not applicable.

Dated this...................................day
of..................................................200....
at...........................................

Witnesses to signature :

1.
..........................................
2. .......................................... Signature of Government servant

(To be filled by the Head of Office)

Nomination by..................................... Signature of Head of Office
Designation.......................................... Date................................................
Office.................................................. Designation.....................................

*    This column should be filled in so as to cover the whole amount of the gratuity.
**  The amount/share of the gratuity shown in this column should cover the whole amount/share payable to the original nominee(s).

 

 

 

 

 

 

 

 

 

 

Pro forma for acknowledging the receipt of the
nomination form by the Head of Office

To

    ...................................................
    ...................................................
    ...................................................

Sir,

    In acknowledging the receipt of your nomination, dated the ................/cancellation, dated the ...............................of the nomination made earlier in respect of gratuity in Form ................................... ,I am to state that it has been duly placed on record.

Signature of Head of Office
Place ...........................................
Dated the .................................... Designation.............................................

    NOTE. - The Government servant is advised that it would be in the interest of his nominees if copies of the nominations and the related notices and acknowledgements are kept in safe custody so that they may come into the possession of the beneficiaries in the event of his death.

 

 

 

 

 

 

 

 

 

 

 

 

FORM 3
Details of Family
[See Rule 54(12)]

Name of the Government servant ... ...............................................................
Designation ... ... ... ..............................................................
Date of birth ... ... ... ..............................................................
Date of appointment ... ... ... .............................................................
Details of the members of my family
*as on ... ... ... .............................................................

Serial
No.
Name of the members of family*
Date of
Birth
Relationship
with the
officer
Initials of
the Head
of Office
Remarks
(1) (2) (3) (4) (5) (6)
1.
2.
3.
4.
5.
6.
7.
8.
9.		          

    I hereby undertake to keep the above particulars up-to-date by notifying to the Head of Office any addition or alteration.

Place............................................. Signature of Government servant
Dated the.......................................  

    *Family for this purpose means family as defined in Clause (b) of sub-rule (14) of Rule 54 of the CCS (Pension) Rules, 1972.

    NOTE. - Wife and husband shall include respectively judicially separated wife and husband.

 

 

 

 

 

FORM 4
[Omitted]

 

 

 

 

 

 

 

FORM 5
[See Rule 59(1)(c) & 61(1)]

Particulars to be obtained by the Head of Office from the retiring Government servant eight months before the date of his retirement
1. Name.
2. (a) Date of birth.
(b) Date of retirement.

3.    1Two specimen signatures (to be furnished in an separate sheet) duly attested by a Gazetted Government servant.

4.    2Three copies of passport size joint 3photograph with wife or husband (To be attested by the Head of Office).

5.    Two slips showing the particulars of height and 4personal identification marks duly attested by a Gazetted Government servant.

6.    Present address.

7.    5Address after retirement.

8.    Name of the Treasury or the Branch of Public Sector Bank or the Pay and Accounts Office through which the pension is to be drawn.

9.    6Details of the family in Form 3.

10.    Indicate whether family pension is admissible from any other source - Military or State Government and/or a Public Sector Undertaking/Autonomous body/Local Fund under the Central or a State Government.

Place................................................ Signature
Dated the......................................... Designation
  Ministry/Deptt./Office

Footnote : 1. Two slips each bearing the left hand thumb and finger impressions duly attested may be furnished by a person who is not literate to sign his name.If such a Government servant on account of physical disability is unable to give left hand thumb and finger impressions he may give thumb and finger impressions of the right hand.Where a Government servant has lost both the hands, he may give his toe impressions. Impressions should be duly attested by a Gazetted Government servant.

                2. Two copies of passport size photograph of self only need be furnished if the Government servant is governed by Rule 54 of the Central Civil Services (Pension) Rules, 1972 and is unmarried of a widower or widow.

                3. Where it is not possible for a Government servant to submit a photograph with his wife or her husband, he or she may submit separate photographs. The photographs shall be attested by the Head of Office.

                4. Specify a few conspicuous marks, not less than two, if possible.

                5. Any subsequent change of address should be notified to the Head of Office.

                6. Applicable only where Rule 54 of the Central Civil Services (Pension) Rules, 1972, applies to the Government servant.

 

 

 

 

 

FORM 6
[Omitted]

 

 

 

 

 

 

 

2FORM 7
(Superscript 2 means Substituted by G.I., Dept. of Pen. & P.W., Notification No. 38/84/89-P. & P.W. (F), dated the 3rd September, 1993.)
See Rule 58,60,61(1) & (3) and 65(1)]

Form for assessing Pension/Family Pension and Gratuity
[To be sent in duplicate if payment is desired in
a different circle of accounting unit]

PART - I

1. Name of the retiring Government employee ... ... ...
2. Father's/Husband's name ... ... ...
3. Height ... ... ...
4. Marks of Identification ... ... ...
5. Date of Birth ... ... ...
6. Service to which belongs (indicate name of organized service, if any, otherwise say, General Central Service)
...
...
...
7. Particulars of post held at the time of retirement -
(a) Name of the Office ... ... ...
(b) Post held ... ... ...
(c) Whether the appointment mentioned above was under Government or outside the Government on foreign service terms

...

...

...
8. Whether declared substantive in any post under the Central Government
...
...
...
9. Date of beginning of service ... ... ...
10. Date of ending of service ... ... ...
11. Cause of ending of service -
(a) Voluntary retirement on being declared surplus (Rule 29)
...
...
...
(b) Permanent absorption in public sector undertaking/autonomous body (Rule 37-A)
...
...
...
(c) Due to abolition of post (Rule 59) ... ... ...
(d) Superannuation (Rule 35) ... ... ...
(e) Invalidment on medical ground (Rule 38) ... ... ...
(f) Voluntary/premature retirement at the initiative of the Government servant [ under Rules 48, 48-A and FR 56 (k) ]

...

...

...
(g) Premature retirement at the initiative of the Government [ Rule 48 or FR 56 (j) ]
...
...
...
(h) Compulsory retirement (Rule 40) ... ... ...
(i) Removal/dismissal from service (Rules 24 and 41) ... ... ...
(j) Death ... ... ...
12. In the case of compulsory retirement, the orders of the competent authority whether pension may be allowed at full rates or at reduced rates and in case of reduced rates, the percentage at which it is to be allowed


...


...


...
13. In case of removal/dismissal from service whether orders of competent authority have been obtained for grant of compassionate allowance and if so, at what rate

...

...

...
14. Particulars relating to military service, if any -
(a) Period of military service ... ... ...
(b) Terminal benefits drawn/being drawn for military service
...
...
...
(c) Whether opted for counting of military service towards civil pension
...
...
...
(d) If answer to (c) above is in the affirmative, whether the terminal benefits have been refunded
...
...
...
(e) In case of ex-servicemen who are eligible for family pension under the Armed Forces Rules, whether opted to retain family pension under the Armed Forces Rules or to draw family pension under the Civil Rules



...



...



...
15. Particulars relating to service in autonomous body, if any -
(a) Particulars of Service :

Name of Organization

Post held

Period

From

To
 

 

      

(b) Whether the above service is to be counted for pension
...
...
...
(c) Whether the autonomous organization has discharged its pensionary liability to the Central Government

...

...

...
16. Whether any departmental or judicial proceedings are pending against the retiring employees
...
...
...
17. Qualifying service -
(a) Detail of omission, imperfection or deficiencies in the Service Book which have been ignored [under Rule 59 (1) (b) (ii) ]

...

...

...
(b) Period not counting as qualifying service -
(i) Boy service (2nd proviso to Rule 13) ... ... ...
(ii) Extraordinary leave not counting as qualifying service (Rule 21)
...
...
...
(iii) Periods of suspension not treated as qualifying service (Rule 23)
...
...
...
(iv) Interruptions in service [Rule 27 (1) (b) and Rule 28 (c)]
...
...
...
(v) Periods of foreign service with United Nations bodies for which United Nations pension has been availed

...

...

...
(vi) Any other period not treated as qualifying service (give details)
...
...
...
(c) Additions to qualifying service -
(i) Military service (Rule 19) ... ... ...
(ii) War service (Rule 20) ... ... ...
(iii) Weightage on voluntary retirement on being declared surplus (Rule 29)
...
...
...
(iv) Weightage under Rule 30 ... ... ...
(v) Benefit of service in an autonomous body (Rule 37) ... ... ...
(vi) Weightage under Rule 48-B ... ... ...
(d) Net qualifying service ... ... ...
(e) Qualifying service expressed in terms of completed six monthly periods (Period of three months & over is to be treated as completed six monthly period.)
...
...
...
18. Emoluments -
(a) Emoluments drawn during 10 months preceding retirement -

From

 To Rate of Pay Amount
 

 

      
(b) If the officer was on foreign service immediately preceding retirement, the notional emoluments which he would have drawn under Government but for being on foreign service


...


...


...
(c) Average emoluments reckoned for pension ... ... ...
(d) Emoluments reckoned for retirement gratuity/death gratuity
...
...
...
(e) Emoluments reckoned for family pension ... ... ...
19. Date on which the retiring employee submitted his application for pension in Form 5
...
...
...
20. Complete and up-to-date details of the family as given in Form 3 -
...
...
...

Sl. No.

1		 Name of the
Member of the
family
2
Date of Birth

3		 Relation with
the Government
servant
4
 

 

      
21. Whether nomination made for death gratuity/retirement gratuity
...
...
...
22. The date on which action initiated to -
(a) obtain the `No demand certificate' from the Directorate of Estates as provided in Rule 57
...
...
...
(b) assess the service and emoluments qualifying for pension as provided in Rule 59 and
...
...
...
(c) assess the Government dues other than the dues relating to the allotment of Government accommodation as provided in Rule 73 (1)

...

...

...
23. Details of Government dues recoverable out of gratuity -
(a) Licence fee for Government accommodation [see sub-rules (2), (3) and (4) of Rule 72]
...
...
...
(b) Dues referred to in Rule 73 ... ... ...
24. (a) Proposed pension/service gratuity ... ... ...
(b) Proposed dearness relief on pension (as on the date of retirement)
...
...
...
(c) Date from which pension is to commence ... ... ...
25. Rate of Family Pension -
(a) Enhanced rate ... ... ...
(b) Period for which family pension will be payable at enhanced rate
...
...
...
(c) Ordinary rate ... ... ...
(d) Date from which ordinary rate of family pension will be payable
...
...
...
26. Amount of retirement gratuity/death gratuity ... ... ...
27. Commutation of pension -
(a) Whether simultaneously applied for commutation of pension with the pension application (applicable only in the case of those who retire on superannuation pension)


...


...


...
(b) The portion of pension commuted ... ... ...
(c) Commuted value of pension ... ... ...
(d) Amount of residuary pension after deducting  Commuted portion
...
...
...
(e) Date from which reduced pension is payable ... ... ...
28. Name and address of Bank/Pension Accounting Office from where pension is to be drawn
...
...
...
29. Head of Account to which pension and gratuity are debitable
...
...
...
30. Post-retirement address of the retiree ... ... ...


Signature of the
Head of Office

PART II

1. Date of receipt of pension papers by the Accounts Officer from Head of Office ... ... ...
2. Entitlements admitted -
A. Length of qualifying service ... ... ...
B. Pension -
(i) Class of pension ... ... ...
(ii) Amount of monthly pension ... ... ...
(iii) Date of commencement ... ... ...
C. Commutation of Pension -
(i) Commuted value of portion of pension commuted, if any
...
...
...
(ii) Residuary pension after commutation ... ... ...
(iii) Date from which reduced pension is payable ... ... ...
(iv) Date of restoration of commuted portion of pension subject to the pensioner continuing to live
...
...
...
D. Retirement/Death Gratuity -
(i) Total amount payable ... ... ...
(ii) Amount to be adjusted towards Government dues ... ... ...
(iii) Amount to be withheld for adjustment of unassessed dues
...
...
...
(iv) Net amount to be released immediately ... ... ...
E. Family Pension -
(i) At enhanced rate ... ... ...
(ii) Period for which Family Pension at enhanced rate is payable
...
...
...
(iii) At normal rate ... ... ...
3. Head of Account to which the amount of pension, retirement/death gratuity and family pension are to be debited
...
...
...


Accounts Officer

1PENSION CALCULATION SHEET
(Superscript 1 means  substituted by G.I., Dept. of P. & P.W., O.M. No. 38/24/91-P. & P.W. (F), dated the 22nd November, 1991.)

Revised Format

1. Name ... ... ...
2. Designation ... ... ...
3. Date of birth ... ... ...
4. Date of entry in the Government service ... ... ...
5. Date of retirement ... ... ...
6. Length of qualifying service reckoned for pension/gratuity (as indicated in PPO)
...
...
...
7. Emoluments drawn during the last 10 months ... ... ...
8. (1) Average emoluments for pension (as indicated in PPO)
...
...
...
(2) Pension admissible
Calculations to be shown as follows :-
Average Emoluments/2 x 2Qualifying Service/66

(Superscript 2 means In completed 6 monthly period, not exceeding 66.)

 ... ... ...
9. (1) Emoluments for gratuity (as indicated in PPO) ... ... ...
(2) Retirement gratuity admissible
Calculation to be shown as follows :-
Emoluments/4 x 2Qualifying Service 		... ... ...
10. (1) Emoluments for Family Pension (as indicated in PPO) ... ... ...
(2) Family Pension admissible
Calculations to be shown as follows :-		 ... ... ...
(a) Ordinary Family Pension :
Pay last drawn x Prescribed % subject to prescribed minimum and maximum
(b) Enhanced Family Pension :
Family Pension at ordinary rate as at (a) above x 2, subject to prescribed minimum and maximum as per Rule 54.

Countersigned

Head of Office
PAO

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM 8
[Form of letter to the Accounts Officer forwarding the
pension papers of a Government servant

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
The Pay and Accounts Officer/
Accountant-General
...............................................
...............................................
...............................................
Subject :- Pension papers of Shri/Shrimati/Kumari............................for authorization of pension.

Sir,

    I am directed to forward herewith the pension papers of Shri/Shrimati/Kumari.........................................of this Ministry/ Department/Office for further necessary action.

    2.    The details of Government dues which will remain outstanding on the date of retirement of the Government servant and which need to be recovered out of the amount of retirement gratuity are indicated below -

(a) Balance of the house-building or conveyance advance...........................................................
...
...
...
Rs.
(b) Overpayment of pay and allowances including leave salary
...
...
...
Rs.
(c) Income Tax deductible at source under the Income Tax Act, 1961 (43 of 1961)
...
...
...
Rs.
(d) Arrears of licence fee for occupation of Government accommodation
...
...
...
Rs.
(e) The amount of licence fee for the retention of Government accommodation for the permissible period of two months beyond the date of retirement


...


...


...


Rs.
(f) Any other assesed dues and the nature thereof ... ... ... Rs.
(g) The amount of gratuity to be withheld for adjustment of unassessed dues, if any
...
...
...
Rs.

Total		 ----------

----------

3.    Your attention is invited to the list of enclosures which is forwarded herewith.

4.    The receipt of this letter may be acknowledged and this Ministry/Department/Office informed that necessary instructions for the disbursement of pension have been issued to disbursing authority concerned.

5.    The retirement gratuity will be drawn and disbursed by this Ministry/Department/Office on receipt of authority from you. The outstanding Government dues as mentioned in para. 2 above will also be recovered out of the retirement gratuity before making payment.

Yours faithfully,    
Head of Office.    

                                                List of enclosures

     1. Form 5*  and Form 7 duly completed.
     2. Medical certificate of incapacity (if the claim is for invalid pension).

      3.    Statement of the savings effected and the reasons why employment could not be found elsewhere (if claim is for compensation pension or gratuity).

      4.    Service Book (date of retirement to be indicated in the service book).

5.   (a) Two specimen signatures, duly attested by a Gazetted Government servant or in the case of pensioner not literate enough to sign his name, two slips bearing the left hand thumb and finger impressions, duly attested by a Gazetted Government servant.
**(b) Three copies of passport size photograph with wife or husband (either jointly or separately) duly attested by the Head of Office.
  (c) Two slips showing the particulars of height and identification marks, duly attested by a Gazetted Government servant.

     6.    A statement indicating the reasons for delay in case the pension papers are not forwarded before six months of the retirement of Government servant.

     7.    Written statement, if any, of the Government servant as required under Rule 59 (1) (a).

     8.    Brief statement leading to reinstatement of the Government servant in case the Government servant has been reinstated after having been suspended, compulsorily retired, removed or dismissed from service.

        NOTE. - When initials or name of the Government servant are or is incorrectly given in the various records consulted, this fact should be mentioned in the letter.

Footnote : * If a Government servant is compulsorily retired from service and delay is anticipated in obtaining Form 5 from the Government servant, the Head of Office may forward the pension papers to the Accounts Officer without Form 5. The Form may be sent as soon as it is obtained from the Government servant.

               ** Only two copies of passport size photograph need be furnished if the Government servant is governed by Rule 54 of the Central Civil Services (Penion) Rules, 1972 and is unmarried or a widower or a widow.

 

 

 

FORM 9
[Omitted]

 

 

 

 

 

 

FORM 10
[Rule 77(2)]
Form of letter to the member or members of the family of a
deceased Government servant where valid nomination
for the grant of the death gratuity exists

 

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
...............................................
...............................................
...............................................
Subject :- Payment of death gratuity in respect of the late Shri/Shrimati........................................

Sir/Madam,

    I am directed to state that in terms of the nomination made by the late Shri/Shrimati....................................(Designation) in the Office/Department/Ministry of..............................a death gratuity is payable to his/her nominee(s). A copy of the said nomination is enclosed herewith.

    2.    I am to request that a claim for the grant of the gratuity may be submitted by you in the enclosed Form 12.

    3.    Should any contingency have happened since the date of making the nomination, so as to render the nomination invalid, in whole or in part, precise details of the contingency may kindly be stated.

Yours faithfully,              
Head of Office.              

 

 

 

 

 

 

 

 

 

 

 

FORM 11
[See Rule 77(2)]
Form of letter to the member or members of the family of a
deceased Government servant where valid nomination for the
grant of the death gratuity does not exist

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
...............................................
...............................................
...............................................
Subject :- Payment of death gratuity in respect of the late Shri/Shrimati........................................

Sir/Madam,

    I am directed to say that in terms of Rule 50 of the Central Civil Services (Pension) Rules, 1972, a death gratuity is payable to the following members of the family of late Shri/Shrimati........................................(Designation), in the Office/Department/ Ministry of ..................................................in equal shares :-

(i) Wife/husband including judicially separated wife/husband.
(ii) Sons including step children and adopted children.
(iii) Unmarried daughters including step children and adopted children.

    2.    In the event of there being no surviving member of the family as indicated above, the gratuity will be payable to the following members of the family in equal shares :-   

(i) widowed daughters including step daughters and adopted daughters;
(ii) father including adoptive parents in case of individuals whose personal law permits adoption ;
(iii) mother including adoptive parents in case of individuals whose personal law permits adoption ;
(iv) brothers below the age of eighteen years and unmarried and widowed sisters including step brothers and step sisters ;
(v) married daughters ; and
(vi) children of a pre-deceased son.

    3.    It is requested that a claim for the payment of gratuity may be submitted in the enclosed Form 12 as soon as possible.

Yours faithfully,           
Head of Office.          

 

 

 

 

 

 

 

 

 

 

 

FORM 12
[See Rule 77(2)]
Form of application for the grant of death gratuity
on the death of a Government servant

(To be filled in separately by each claimant and in case the claimant is minor, the Form should be filled in by the guardian on his/her behalf. Where there are more than one minor, the guardian should claim gratuity in one Form on their behalf}

1. (i)

Name of the claimant in case he is not minor

 ... ... ...
(ii) Date of birth of the claimant ... ... ...
2. (i) Name of the guardian in case the claimants are minors
...
...
...
(ii) Date of birth of the guardian ... ... ...
3. (i) Name of the deceased Government servant in respect of whom gratuity is being claimed
...
...
...
(ii) Date of death of Government servant ... ... ...
(iii) Office/Department/Ministry in which the deceased served last
...
...
...
4. Relationship of the claimant/guardian with the deceased Government servant
...
...
...
5. Full Postal Address of the claimant/guardian ... ... ...
6. (i) Where gratuity is claimed by the guardian on behalf of minors, the names of the minors, their ages, relationship with the deceased Government servant, etc. -


...


...


...
Serial
No.		 Name Age Relationship with the
deceased Government
servant		 Postal Address
1.
2.
3.
4.		        

(ii)

 Relationship of the guardian with minor ... ... ...


7.


Place of payment of Pension and Gratuity (Treasury, Sub-Treasury, Public Sector Bank branch, or the Pay and Accounts Office)


...


...


...


Signature/Thumb-
impression of the claimant/guardian

8.
Two specimen signatures 1or left hand thumb and finger impressions of the claimant/guardian duly attested
(To be furnished in a separate sheet)

...

...

...

9.
2Attested by -

Name

Full Address

Signature
(i) .......................................... ............................................... ................................................
(ii) .......................................... ............................................... ................................................

10.
Witnesses:
(i) .......................................... ............................................... ................................................
(ii) .......................................... ............................................... ................................................

Footnote : 1. To be furnished in case the applicant is not literate enough to sign his name.
                2. Attestation should be done by two Gazetted Government servants or two or more persons or respectability in the town, village or Pargana in which the applicant resides.

 

 

 

 

 

 

 

 

 

 

FORM 13
[See Rule 77(3)]
Form of letter to the widow/widower of a deceased Government
servant for grant of Family Pension, 1964

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
...............................................
...............................................
...............................................
Subject :- Payment of Family Pension, 1964, in respect of the late Shri/Shrimati........................................

Sir/Madam,

    I am directed to state that in terms of Rule 54 of the Central Civil Services (Pension) Rules, 1972, a family pension, 1964, is payable to you as widow/widower of the late Shri/Shrimati...........................................(Designation) in the Office/Department/ Ministry of ..........................................

    2.    You are advised that a claim for the grant of Family Pension, 1964, may be submitted in the enclosed Form 14.

    3.    The Family Pension, 1964, will be payable till your death or remarriage, whichever event occurs earlier. In the event of your death or remarriage, the Family Pension, 1964, shall be granted to the child or children, if any, through the guardian.

Yours faithfully,        
Head of Office.        

 

 

 

 

 

 

 

 

 

 

 

FORM 14
[See Rule 77(3) and 81(2)]

Form of application for the grant of Family Pension, 1964,
on the death of a Government servant/pensioner

1. Name of the applicant ... ... ...
(i) Widow/Widower ... ... ...
(ii) Guardian if the deceased person is survived by child or children
...
...
...
2. Name and age of surviving widow/widower and children of the deceased Government servant/pensioner served last

...

...

...
Serial
No.		 Name Relationship with
the deceased person		 Date of birth
by Christian era
1.
2.
3.
4.
5.
6.		      

3.
Name and No. of the PPO of the deceased pensioner

...

...

...
4. Date of death of the Government servant/pensioner ... ... ...
5. Office/Department/Ministry in which the deceased Government servant/ pensioner served last
...
...
...
6. If the applicant is guardian, his date of birth and relationship with the deceased Government servant/pensioner

...

...

...
6-A If the applicant is a widow/widower the amount of service pension which she/he may be in receipt on the date of death of the husband/wife

...

...

...
7. Full address of the applicant ... ... ...
8. Place of payment of Pension and Gratuity (Treasury, Sub-treasury or Public Sector Bank Branch and Pay and Accounts Office)

...

...

...
9. Enclosures :
(i) Two specimen signatures of the applicant, duly attested (To be furnished in two separate sheets).
(ii) Two copies of passport size photograph of the applicant, duly attested.
(iii) Two slips each bearing left hand thumb and finger impressions* of the applicant, duly attested.
(iv) Descriptive Roll of the applicant, duly attested, indicating (a) height and (b) personal marks, if any, on the hand, face, etc. (Specify a few conspicuous marks, not less than two, if possible.)
(To be furnished in duplicate.)
(v) Certificate(s) of age (in original with two attested copies) showing the dates of birth of the children. The certificate should be from the Municipal Authorities or from the local panchayat or from the head of a recognised school if the child is studying in such school. (This information should be furnished in respect of such child or children, the particulars of whose date of birth are not available with the Head of Office).
10. Indicate whether family pension is admissible from any other source - Ministry or State Government and/or a public sector undertaking/autonomous body/local fund under the Central or a State Government


...


...


...
11. Signature or left hand thumb-impression* of the applicant
...
...
...
12. Attested by :
   

Name

Full Address

Signature
  (i) ............................................ ............................................. ..........................................
  (ii) ............................................ ............................................. ..........................................
13. Witnesses :
    Name Full Address Signature
  (i) ............................................ ............................................. ..........................................
  (ii) ............................................ ............................................. ..........................................

    NOTE. - Attestation should be done by two Gazetted Government servants or two or more persons of respectability in the town, village or Pargana in which the applicant resides.

*To be furnished in case the applicant is not literate enough to sign his name.

 

 

 

 

FORM 15
[Omitted]


FORM 16
[Omitted]

FORM 17
[Omitted]

 

 

 

 

 

 

 

FORM 18
[See Rules 78(1),80(1), 80(3) and 880(5) and 80-B (1) & 80-B (5)]
Form for assessing and authorising the payment of family pension
and death gratuity when a Government servant dies while in service
(To be sent in duplicate if payment is desired in a
different Circle of accounting unit)

PART I

Section I

1. Name of the deceased Government servant ... ... ...
2. Father's name (and also husband's name in the case of female Government servant)
...
...
...
3. Date of birth (by Christian era) ... ... ...
4. Date of death (by Christian era) ... ... ...
5. Religion ... ... ...
6. Office/Department/Ministry in which last employed ... ... ...
7. Appointment held last ... ... ...
(i) substantive ... ... ...
(ii) officiating ... ... ...
8. Date of beginning of service ... ... ...
9. Date of ending of service ... ... ...
10. (i) Total period of military service for which pension, gratuity was sanctioned ; and
...
...
...
(ii) Amount and nature of any pension, gratuity received for the military service
...
...
...
11. Amount and nature of any pension received for previous civil service, if any
...
...
...
12. Government under which service has been rendered in order of employment
...
...
...
13. The date on which intimation regarding the death of Government servant was received by the Head of Office
...
...
...
14. The date on which action initiated to -
(i) obtain claim or claims from the claimants in the appropriate form for death gratuity and family pension as provided in Rule 77 ;
(ii) obtain the `No demand certificate' from the Directorate of Estates as provided in Rule 80-C (1) ;
(iii) assess the Government dues other than the dues pertaining to occupation of Government accommodation as provided in Rule 80-C (2) ; and
(iv) assess the service and emoluments qualifying for death gratuity and family pension as provided in Rules 78 and 79.
15. Whether nomination made for death gratuity
16. Length of service qualifying for death gratuity/pension ... ... ...
17. Periods of non-qualifying service - From To
(i) Interruption in service condoned under Rule 28 ... ... ...
(ii) Extraordinary leave not qualifying for gratuity ... ... ...
(iii) Period of suspension treated as non-qualifying ... ... ...
(iv) Any other service not treated as qualifying service ... ... ...

Total period of non-qualifying service
...
...
...		   --------------------------
 
---------------------------
18. (a) Emoluments reckoning for death gratuity ... ... ...
(b) Amount of death gratuity ... ... ...
19. Omitted.
20. Omitted.
21. (i) If Family Pension, 1964 applies ---
Proposed Family Pension at -
(a) enhanced rates [if service rendered at the time of death is more than seven years as in Rule 54 (3)]
...
...
...
(b) ordinary rates - [as in Rule 54 (2)] ... ... ...
(ii) Period of tenability of Family Pension - From To
(a) enhanced rates ... ... ...
(b) ordinary rates ... ... ...
22. Persons to whom family pension is payable -
Name ... ... ...
Relationship with the deceased Government servant ... ... ...
Full postal address ... ... ...
23. Details of Government dues recoverable out of gratuity -
(i) Licence fee for occupation of Government accommodation [See Rule 80-C]
...
...
...
(ii) Amount of death gratuity to be held over pending receipt of information from the Directorate of Estates
[See Rule 80-C (i) (v)]
...
...
...
(iii) Dues referred to in Rule 80-C (2) ... ... ...
24. Date on which claims received from the claimants ... ... ...
25. Name of guardian who will receive payment of death gratuity and family pension in the case of minors
...
...
...
26. Place of payment (Treasury, Sub-Treasury or Branch or Public Sector Bank or the Pay and Accounts Office)
...
...
...
27. Head of Account to which death gratuity and family pension are debitable
...
...
...

Place
Dated the


Signature of
Head of Office

Section II

    Details of provisional family pension and gratuity to be drawn and disbursed by the Head of Office in accordance with Rule 80A.

Provisional family pension ... ... ... Rs................................p.m.
Gratuity [the amount mentioned in item 18 (b) of Part I] ... ... ... Rs......................................
Less          
  (a) Licence fee recoverable from gratuity for occupation of Government accommodation [as in item 23 (i) of Part I]

...

...

...

Rs................................p.m.
  (b) Amount of gratuity to be held over pending receipt of information from the Directorate of Estates [as the item 23 (ii) of Part I]

...

...

...

Rs......................................
  (c) Other Government dues as mentioned in item 23 (iii) of Part I ... ... ... Rs......................................
  (d) Total of (a), (b) and (c) ... ... ... Rs......................................

Place
Dated the


Signature of
Headof Office

PART II
Account Enfacement

Section I

1. Total period of qualifying service which has been accepted for -          
  (i) Death gratuity ... ... ...    
  (ii) Family Pension, 1964 ... ... ...    
2. Net amount of gratuity after adjusting Government dues ... ... ...    
3. Net amount of gratuity of tenability of Family Pension, 1964. If death took place -       Amount
--------
Rs.		 Period of
tenability
---------
From  To
  (i) before seven years service ... ... ...    
  (ii) after seven years service ... ... ...    
4. Date from which Family Pension is admissible ... ... ...    
5. Head of Account to which death gratuity and family pension are chargeable
...
...
...		    

Section II
1. Name of the deceased Government servant ... ... ...    
2. Date of death of the Government servant ... ... ...    
3. Date on which pension papers received by the Accounts Officer
...
...
...		    
4. Amount of family pension authorised ... ... ...    
5. Amount of gratuity authorised ... ... ...    
6. Date of commencement of family pension ... ... ...    
7. Date on which payment of family pension and gratuity authorised
...
...
...		    
8. Amount recoverable from gratuity ... ... ...    
9. Amount of gratuity held over pending receipt of `No demand certificate'
...
...
...		    

Place
Dated the



Accounts Officer

 

 

 

 

 

 

 

 

 

 

 

FORM 19
(See Rule 81)
Form of letter to the Accounts Officer forwarding papers for the
grant of family pension and death gratuity to the family of a
Government servant who dies while in service

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
The Pay and Accounts Officer/
Accountant-General
...............................................
...............................................
...............................................
Subject :- Grant of family pension and death gratuity.

    I am directed to say that Shri.............................designation...................................died on.............................. His family has become eligible for the grant of family pension and death gratuity. Form 18 duly completed is forwarded herewith for further necessary action.

    2.    Government dues in respect of the deceased Government servant will be recovered out of the death gratuity as indicated in Section II of Part I of Form 18.

    3.    Your attention is invited to the list of enclosures which is forwarded herewith.

    4.    The receipt of this letter may be acknowledged and this Ministry/Department/Office informed that necessary instructions for the disbursement of family pension and death gratuity have been issued to the disbursing authority concerned.

Yours faithfully,
Head of Office.

List of enclosures

1.    Form 18 duly completed.

2.    Service book (date of death to be indicated in the service book).

3.    Two specimen signatures or left hand thumb and finger impressions of the claimant or guardian duly attested.

4.    Two copies of passport size photograph of the claimant or guardian duly attested.

5.    Two copies of descriptive roll of the claimant or guardian duly attested indicated height and personal marks.

6.    Postal address of the claimant or guardian.

 

 

 

 

 

 

 

 

 

 

 

FORM 20
[ See Rule 81(2)]
Form of letter sanctioning Family Pension to the child or
children of a retired Government servant who dies after
retirement but does not leave behind a widow or widower

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
The Pay and Accounts Officer/
Accountant-General
...............................................
...............................................
...............................................
Subject :- Grant of Family Pension,1964 to the child/children.

Sir,

    I am directed to say that Shri/Shrimati.................................................. formerly........................................... (Designation) in this Ministry/Department was authorised pension of Rs................................ with effect from ................................. on his/her retirement from service.

2.    Intimation has been received in this Ministry/Department/Office that Shri/Shrimati..................................... died on ............ and that at the time of death left no widow/widower but was survived by the following children* :-

Sl.
No.		 Name Son/
Daughter		 Date of birth
in Christian era		 Date from which
family pension
ceases to be payable
(1)
(2)
(3)
(4)		        

3.    In terms of Rule 54 of the Central Civil Services (Pension) Rules, 1972, the amount of Family Pension has become payable to the children in the order mentioned above. The Family Pension will be payable on behalf of the minor to Shri/Shrimati .............................................. who is the guardian.

4.    Sanction for the grant of Family Pension of Rs..............................per month to the children mentioned above is hereby accorded. The Family Pension will take effect from..............................and subject to the provisions of sub-rule (6) of Rule 54 of the Central Civil Services (Pension) Rules, 1972, will be tenable till.................................

5.    The Family Pension is debitable to the Head.........................................

6.    Attention is invited to the information furnished in the list of enclosures.

7.    The receipt of this letter may kindly be acknowledged and the Ministry/Department/Office informed that instructions for the payment of Family Pension, to the guardian have been issued to the disbursing authority concerned.

Yours faithfully,
Head of Office.

List of enclosures

1.    Permanent address of the guardian.

2.    Place of payment (Government Treasury, Sub-Treasury or Branch of Public Sector Bank or Pay and Accounts Office).

3.    Specimen signature or **[left hand thumb and finger impressions of the claimant or guardian duly attested.

4.    Two attested copies of passport size photograph of the guardian.

5.    Descriptive roll of the guardian, duly attested.

Footnote : * The names of children should be mentioned in the order of eligibility mentioned in Rule 54 of the Central Civil Services (Pension) Rules, 1972.

                ** To be furnished in the case of the guardian who is not literate enough to sign his or her name.

 

 

 

 

 

 

 

 

 

 

 

FORM 21
[ See Rule 81(2)]

Form of letter sanctioning Family Pension to the child or children
on the death or re-marriage of a widow/widower who was
in receipt of Family Pension

No....................................................
Government of India
Ministry of........................................
Department/Office.............................
Dated the..........................................
To
The Pay and Accounts Officer/
Accountant-General
...............................................
...............................................
Subject :- Grant of Family Pension to the child/children.

Sir,

I am directed to say that Shri/Shrimati....................................widow/widower of late Shri/Shrimati............................. formerly.....................................(designation) in this Ministry/Department/Office was authorised the payment of Family Pension of Rs.................................with effect from..................................... The Family Pension was tenable till the death or re-marriage of the widow/widower.

2.    Intimation has been received in this Ministry/Department/Office that Shri/Shrimati.................................................... died/re-married on....................................

3.    At the time of death/re-marriage Shri/Shrimati................................................ had following children* :-

Sl.
No.		 Name Son/
Daughter		 Date of birth
in Christian era		 Date from which
family pension
ceases to be payable
(1)
(2)
(3)
(4)		        

4.    In terms of Rule 54 of the Central Civil Services (Pension) Rules, 1972, the amount of Family Pension has become payable to the children in the order mentioned above. The Family Pension will be payable on behalf of the minors to Shri/Shrimati..................................................who is the guardian.

5.    Sanction for the grant of Family Pension Rs...........................per month to the children, mentioned above is hereby accorded. The Family Pension will take effect from.................................and subject to the provisions of sub-rule (6) of Rule 54 of the Central Civil Services (Pension) Rules, 1972, will be tenable till.......................................

6.    The Family Pension is debitable to the Head..............................................

7.    Attention is invited to the information furnished in the list of enclosures.

8.    The receipt of this letter may kindly be acknowledged and this Ministry/Department/Office informed that necessary instructions for the payment of Family Pension to the guardian have been issued to the disbursing officer concerned.

Yours faithfully,
Head of Office.

List of enclosures

1.    Permanent address of the guardian.

2.    Place of payment (Government Treasury, Sub-Treasury, Branch of Public Sector Bank or Pay and Accounts Office).

3.    Specimen signature or **left hand thumb and finger impressions of the guardian, duly attested.

4.    Two attested copies of passport size photograph of the guardian.

5.    Descriptive roll of the guardian, duly attested.

Footnote : * The names of children should be mentioned in the order of eligibility mentioned in Rule 54 of the Central Civil Services (Pension) Rules, 1972.

                ** To be furnished in the case of the guardian who is not literate enough to sign his or her name.

 

 

 

 

 

 

 

 

 

 

 

FORM 22
[ See Rule 81(4)]
Form of application for the grant of Residuary1 Gratuity
on the death of a pensioner

(To be filled in separately by each applicant)

1. Name of the applicant ... ... ...
2. (i) Name of the guardian in case the applicant is a minor
...
...
...
(ii) Date of birth of guardian ... ... ...
3. Name of the deceased pensioner ... ... ...
4. Office/Department/Ministry in which the deceased pensioner served last
...
...
...
5. Date of death of the pensioner ... ... ...
6. Date of retirement of the deceased pensioner ... ... ...
7. Amount of monthly *pension (including ad hoc increase, if any) sanctioned to deceased pensioner
...
...
...
8. Amount of retirement gratuity received by the deceased pensioner
...
...
...
9. The amount of *pension (including ad hoc increase, if any) drawn by the deceased till the date of death
...
...
...
10. If the deceased had commuted a portion of pension before his death, the commuted value of the pension

...

...

...
11. Total of items 8,9 and 10 ... ... ...
12. Amount of death gratuity equal to 12 times of the emoluments
...
...
...
13. The amount of residuary gratuity claimed, i.e., the difference between the amount shown against items 12 and 11

...

...

...
14. Relationship of the applicant with the deceased pensioner
...
...
...
15. Date of birth of the applicant ... ... ...
16. Name of the Treasury or Sub-Treasury at which payment is desired
...
...
...
17. Full address of the applicant ... ... ...
18. Signature or thumb-impression of the applicant (To be furnished in a separate sheet duly attested.**)
...
...
...
19. Attested by :
Name Full Address Signature
(i) ....................................... ........................................... ........................................
(ii) ....................................... ........................................... ........................................
20.

Witnesses
Name Full Address Signature
(i) ....................................... ........................................... ........................................
(ii) ....................................... ........................................... ........................................

Footnote : 1. If a retired Government servant in receipt of service gratuity or pension dies within five years from the date of his retirement from service including compulsory retirement as a penalty and the sums actually received by him at the time of his death on account of such gratuity or pension including ad hoc increase, if any, together with the death-cum-retirement gratuity and the commuted value of any portion of pension commuted by him are less than the amount equal to 12 times of his emoluments, a residuary gratuity equal to the deficiency becomes payable to the family.

            * When a Government servant has retired before earning a pension, the amount of service gratuity should be indicated.
            ** Attestation should be done by two Gazetted Government servants or by two or more persons of respectability in the town, village or pargana in which the applicant resides.

 

 

 

 

 

 

 

 

 

 

 

 

FORM 23
[ See Rule 38(3)]
Form of Medical Certificate

   Certified that *I/(We) have carefully examined AB son of CD a .............................in the..........................His age by his own statement is..............................years, and by appearance about.............................years. I/(We) consider AB to be completely and permanently incapacitated for further service of any kind in the Department to which he belongs in consequence of ........................... (here state disease or cause).

    (If the incapacity does not appear to be complete and permanent, the certificate should be modified accordingly and the following addition should be made.)

    *I am/We are of opinion that AB is fit for further service of a less laborious character than that which he had been doing/may, after resting for..............................months. be fit for further service of less laborious character than that which he had been doing.

Medical Authority

Place
Dated the

Footnote : * Strike out whichever is not applicable.

 

 

 

 

 

 

 

 

 

 

FORM 24
[ See Rule 32]
Form of certificate of verification of service for pension

No.....................................................
Government of India
Ministry of .........................................
Department of.....................................
Dated.................................................

Certificate

   It is certified, in consultation with the Accounts Officer, that Shri .................................. Designation ................................. has completed a qualifying service of .................................. years ............................... months, ............................. days as on.................................(date), as per details given below. The service has been verified on the basis of his service documents and in accordance with the rules regarding qualifying service in force at present. The verification of service under sub-rules (1) and (2) of Rule 32 of the Central Civil Services (Pension) Rules, 1972, shall be treated as final and shall not be re-opened except when necessitated by a subsequent change in the rules and orders governing the conditions under which the service qualifies for pension.

DETAILS OF QUALIFYING SERVICE

    From To

1.
2.
3.

      

Signature of Head of Office     

To

    Shri.................................................
    (Name and Designation)

 

 

 

 

 

 

 

 

 

 

 

 

1FORM 25
(Superscript 1 Inserted by G.I., Dept. of Per. & A.R., Notification No. 29/4/83-Pension Unit, dated the 15th November, 1984.)
[ See Rule 10(1)]
Form of application for permission to Central Services Officers
to accept commercial employment within a period
of two years after retirement

1. Name of the Officer
(in BLOCK letters)		 ... ... ...
2. Date of retirement ... ... ...
3. Particulars of the Ministry/Deptt./Office in which the officer served during the last 5 years preceding retirement (with duration) :      
Name of Ministry/
Department Office		 Post held Duration
From To
       
4. Post held at the time of retirement and period for which held ... ... ...
5. Pay scale of the post and pay drawn by the Officer at the time of retirement ... ... ...
6. Pensionary benefits :      
Pension expected/sanctioned
(commutation if any, should be mentioned}		 Gratuity, if any
   
7. Details regarding commercial employment proposed to be taken up -      
  (a) Name of the firm/company/Co-operative Society, etc. ... ... ...
  (b) Products being manufactured by the firm/type of business carried out by the firm, etc. ... ... ...
  (c) Whether the official had during his official career, any dealings with the firm, etc. ... ... ...
  (d) Duration and nature of the official dealings with the firm ... ... ...
  (e) Name of the job/post offered ... ... ...
  (f) Whether post was advertised, if not, how was offer made (attach newspaper cutting of the advertisement, and a copy of the offer of appointment, if any)


...


...


...
  (g) Description of the duties of the job/post ... ... ...
  (h) Remuneration offered for post/job ... ... ...
  (i) If proposing to set up a practice, indicate -      
    (a) Professional qualification/in the field of practice ... ... ...
    (b) Nature of proposed practice ... ... ...
8. Any information which the applicant desires to furnish in support of his request ... ... ...
9. Declaration :-      
  I hereby declare that -      
  (i) the employment which I propose to take up will not bring me into conflict with Government ;
  (ii) my commercial duties will not be such that my previous official position or knowledge or experience under Government could be used to give my proposed employer an unfair advantage ;
  (iii) my commercial duties will not involve liaison or contact with the Government departments.

Dated:
Signature of the applicant
Address :

STATEMENTS FOR MONITORING AND REPORTING SYSTEM

Statement No.1

Monthly statement showing particulars of Government servants
who became due for retirement in the next eight months

(To be submitted by the Head of Office to the next higher Officer)

Statement for the month of .......................................200...  .

Name of the Office......................................................................... Place...........................................................
1 2 3 4 5 6
Sl. No. Name of the Government servant due for retirement Designation Date of retirement Whether action to complete pension papers was initiated two years in advance of retirement [cf. Rule 58 and Rule 59 of the CCS (Pension) Rules, 1972] Present stage
of the case
[cf. para. 8 of OM, dated 28-2-76]
           

Statement No. 2

Monthly statement showing particulars of Government servants
who became due for retirement in the previous calendar month
and the date of authorisation of final pension

(To be submitted by the Head of Office to the next higher Officer)

Statement for the month of ................................................200...  .

Name of the Office......................................................................... Place...........................................................

Part I

1 2 3 4 5 6 7 8



Sl.
No.
Name of the Government
servant who
retired in the preceding
month


Designation

Date
of
retirement
Number
and date
of final
pension
payment
order,
if issued		 If final PPO not issued by the date of retirement, the date on which Provisional Pension and Gratuity authorised by the Head of Office and date of disbursement of the pension due for the first month after retirement
In case gratuity was not authorised or a portion of it was withheld and
the amounts subsequently paid, the Number, Amount, date of bill, cheque/draft and date of its disbursement



Remarks
               

Part II

1 2 3 4 5





Sl. No.


Total number
of Government servants who retired during the preceding month

Total number of Government servants in whose case the final PPO and final Order for gratuity issued before the date of retirement of Government servants		 Total number of Government servants in whose case final PPO, etc., has not been issued but provisional pension and gratuity authorised by the Head of Office to be paid in the month following the month of retirement of Government servants

Total number of cases where provisional pension and gratuity was not authorised immediately on retirement and reasons therefor. [Col. 2 minus (Col. 3 + Col. 4)]
 

 

        

NOTE. - Part II of the Statement is to be submitted by the next higher officer to the Head of the Department.

Statement No. 3

Quarterly Statement showing particulars of Government servants in
whose case final pension payment order was not issued within
six months of retirement and where provisional pension
had to be made final
[To be submitted to the Head of Department]

Statement for the Quarter ending
*31st March/30th June/30th September/31st December

Name of the Office............................................................................... Place..................................................................
1 2 3 4 5 6 7 8
Sl.
No.		 Name of retiring Government servant Designation Date of retirement Date of authorisation of provisional pension Date on which provisional pension made final Reason for non-determination of final pension Remarks
 

 

              

Statement No. 4

Quarterly Statement showing particulars of Government servants
where presumptions have been made in favour of retiring
Government servants because of incomplete/improper
maintenance of service records

(To be submitted to the Head of Department one quarter
in arrear, i.e., Statement of Quarter ending 31st March
to be submitted in July of the year)

Name of the Office............................................................................... Place..................................................................

Statement for the Quarter ending
*31st March/30th June/30th September/31st December

1 2 3 4 5 6 7 8 9





Sl.
No.

Name of the retiring Government servant




Designation



Date of retirement



Date on which final PO issued



The nature of presumption made		 Monetary effect of presumption, i.e., the amount by which the pension/gratuity of the Government servant has increased because of presumption
Officer(s) responsible for improper maintenance of record
Action taken against the officer responsible for lapse
 

 

                

Statement No. 5

Half-yearly Statement showing particulars of Government servants in
whose case pension was not determined within six months of retirement

(To be submitted by the Head of the Department to the
Secretary of the Department)

Statement for the half-year ending 30th June/ 31st December

Name of the Department/Ministry.................................................................................................................................

1 2 3 4 5 6 7
Sl.
No.		 Name of the retiring Government servant Designation Date of retirement Date on which provisional pension authorised Date on which provisional pension made final Reason for non-determination of final pension within six months of retirement