APPLICATION FOR PENSION

FROM:

A/C.NO ……

GPF A/C.NO … TO, THE PCDA (PENSION),ALLAHABAD-211014

(Through Proper channel)

SUB: APPLICATION FOR SANCTION OF PENSION/GRATUITY

Sir,

I request to state that I am due to retire from service wef .. my date of birth being I therefore request that steps may kindly be taken with a view to sanction pension and gratuity as admissible under CCS Rules. I desire to draw my pension from the office of …………. or…………… Treasury/Bank.

2. I hereby declare that I have neither applied for, nor received any pension or gratuity in respect of any portion of the service, qualifying for pension and in respect of which pension/gratuity are claimed herein nor shall I submit an application hereafter without quoting a reference to this application and the orders, which may be passed hereon.

3. I am governed by Rule 54 of CCS (Pension) Rules 1972 and the details of family are furnished in Form 3 including Handicapped Child (if applicable)

4. I have enclosed herewith documents as per your office letter no. …

My present address is

My permanent settlement address after retirement will be:

PLACE: SIGNATURE

DATE: DESIGNATION :

I A F A – 356APPLICATION FOR PENSION OR GRATUITY AND DEATH-CUM-

RETIREMENT GRATUITY UNDER CIVIL RULES

1. Name of applicant (in Block Letters) :

2. Father’s Name/Husband’s Name : (in the case of a female Govt. servant)

[in Block Letters]: 3. Religion and Nationality (in Block Letters):

4. Residence showing Village, Pargana, : District

State (in Block Letters)

5. Present or last employment including name of establishment: (a) Substantive appointment: 6. Date of beginning of service :7. Date of ending of service :

(a) Total period of military service : (b) Date of commencement and end of

military service: (c) Amount and nature of any pension/ gratuity received for the military service:

8. Length of service, including interruption of which non-qualifying and interruptions. :

(a) Total qualifying service :

(b) Qualifying military service reckonable for civil pension :

(c) Total service qualifying for civil pension : /gratuity:

9. Class of pension or gratuity applied and cause of application :

(a) Pension Rules opted/eligible:

10. Whether nomination made for: (i)Death-cum-retirement gratuity: (ii)Family pension under Liberalised Pension Rules:11. Average emoluments for the last three years (a)Rate of emoluments last drawn 12. Proposed Pension

(a) Proposed gratuity

(b) Proposed death-cum-retirement gratuity:

13. Date from which pension to commence

14. Place of payment (in Block Letters)

15. Date of applicant’s birth by Christian era

16. Height

17. Identification marks

18. Date of first application for pension19. Impression of balls of thumb and all the fingers of the left hand (right hand in the case of a female Govt. servant)20. Govt. under which service has been rendered in the order of employment, (the details may, where necessary) be recorded on a separate sheet to be pasted on this page.

21. Name of wife:

22. Descriptive Roll:

(i) Date of birth by Christian era :

(ii) Height :

(iii) Marks of Identification :

(iv) Signature on a separate sheet of paper : duly attested

(v) Right hand thumb and finger impressions (in the Case of illiterate) on a separate sheet of paper Duly attested:

Signature of Head of Office/Dept. If the application is for a compensation, pension or gratuity, the nature of the change of establishment which has given rise to the claim should be fully stated The term “emoluments” should be taken as defined in Art.486/486-A,C.S.R. If not known exactly, must be stated on the best information or estimate In case European Ladies, Gazetted Officer, Government title holder and other persons who may be specially exempted by Government, thumb and finder impressions and particulars of height and personal marks are not required. Formal application on form 30 C.S.R. as per annexure if to Govt. of India, Ministry of Defence O.M. No. F.18(9)59/111517/D (Civ.I) dated 5-10-59 should accompany this form.

FORM- (3)

DETAILS OF FAMILY

1. Name of the Government Servant: :

2. Designation : 3. Date of Appointment :

Details of the member of my family as on: (including Handicapped Child)

Sl.no Name of the members of

family

Date of birth Relationship with the govt.

servant

Initial Remarks

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

Place:

Date

Signature of the Applicant

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

DESCRIPTIVE ROLL DESCRIPTIVE ROLL OF CLAIMANT

i) Sri/Smt. :

i) Date of birth by Christian Era : :

ii) Height: :

iii) Marks of identification: :

iv) Signature :

v) Left/Right hand thumb & finger impression: RIGHT HAND LEFT HAND

THUMB THUMB

FORE FINGER FORE FINGER

MIDDLE FINGER MIDDLE FINGER

RING FINGER RING FINGER

LITTLE FINGER LITTLE FINGER

Name of the treasury at whichPayment is desired:

Date:Permanent address of Sri/Smt. .

SIGNATURE

SPECIMEN SIGNATURE OR THUMB IMPRESSION

1.

2.

3. ATTESTED

DECLARATION IN TERMS OF ARTICLE 922 (a) C.S.R.VIDE AMENDMENT LIST NO.176 OF 1942.

Where as the government has consented provisionally to advance to me the sum of Rs…………..a month, in anticipation of the completion of enquiries necessary to enable the government to fix the amount of my pension. I hereby acknowledge that in accepting this advance I fully understand that my pension is subject to revision on the completion of the necessary formal enquiries and I promise to base no objection to such revision on the ground that the provisional Pension now to be paid to me exceeds the pension to which I may eventually be found entitled. I further promise to repay any amount advanced to me in excess of the pension to which I may be eventually found entitled.

Signature:

Name in Block Letters: :

Grade :

A/C. No: Witness

Signature:

Name in Block Letters:

Grade:

A/C. No:

 

FORM OF OPTION

ANNEXURE- I

I, Shri/ Smt ….hereby opt the medical facilities under CGHS or similar Health Schemes namely …………..

or

2. I, Shri/Smt……………… hereby opt to claim fixed medical allowance of Rs. 100/- as I am residing in area where no CGHS Medical facilities are available.

Existing Address

Signature.

Name in Block letter :

Designation :

Office in which employed .

Date

Station :

i. To be scored out if not applicable ii. This is one time option.

FORM-5(See Rules 59(I)(c) and 61 (I)

PARTICULARS TO BE OBTAINED BY THE HEAD OF THE OFFICE FROM THE RETIRING GOVERNMENT SERVANT EIGHT MONTHS BEFORE THE DATE OF HIS RETIREMENT

**********************1. Name(a) Date of Birth(b) Date of retirement

2. Three specimen signatures duly attested (to be furnished in a separate sheet) by a Gazetted Government servant.

3. Three copies of Passport size joint photograph with wife or husband (to be attested by the Head of Office.)

4. Three slips showing the particulars of Height and personal identification marks duly attested by a Gazetted Government servant.

5. Present address

6. Address after retirement

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

8. Details of the family in Form-3

9. Indicate whether family pension is admissible from any other sources, Military or State Government and or a Public Sector Undertaking/Autonomous Body/Local Fund under the Central or a State Government.

10. A certificate that No Government demands are outstanding against the retiring Government servant.

Place: Date:

Signature:FORM - 1A

[See Rule 5(2), 12, 13(3), 14(1) and 15(3)]

FORM OF APPLICATION FOR COMMUTATION OF FRACTION OF SUPERANNUATION PENSION WITHOUT MEDICAL EXAMINATION WHEN APPLICANT DESIRES THAT THE PAYMENT OF THE COMMUTED VALUE OF PENSION SHOULD BE AUTHORISED THROUGH THE PENSION PAYMENT ORDER

(To be submitted in duplicate at least three months before the date of Retirement)PART - I

The PRICIPLE CONTROLLER OF DEFENCE ACCONTS SUB: COMMUTATION OF PENSION WITHOUT MEDICAL EXAMINATION Sir,I desire to commute a fraction of my Pension in accordance with the provisions of the Central Civil Services [Commutation of Pension] Rules 1981. The necessary particulars are furnished below :-1. Name in Block letters :

2. Father’s Name (and also husband’s : in case of female Govt. Servant) 3. Designation : 4. Name of Office/Department/ Ministry in which employed. 5. Date of Birth (By Christian era) : 6. Date of retirement on Superannuation or on the expiry of extension in service : granted under FR 56 (d)7. Fraction of Superannuation Pension : proposed to be commuted8.Disbursing Authority from which Pension : is to be drawn after retirement ( a) Treasury/Sub-Treasury (Name& Complete address of Treasury/ : Sub-Treasury to be indicated) (i) Branch of the nominated Nationalised Bank with complete Postal Address: Bank Account No. to which Monthly Pension is to be credited each month*The Applicant should indicate the fraction of the amount of monthly pension (subject to a maximum of 40% thereof), which he/ she desires to commute and not the amount in Rupees

PART- II( ACKNOWLEDGEMENT )

Received from Shri/Smt/Kum Application in Part –I of Form IA for commutation of a fraction of Pension without Medical examination.

Place : Sign. of Head of Office

Date :Note: If application has been received by the Head of Office before the date of Retirement on Superannuation, this acknowledge should be detached from the form and handed over to the applicant. If the form has been received by post, it has to be acknowledged on the same day and the acknowledgement sent under registered cover to the applicant. In case it is received after the specified date, it should be accepted only if it has been put into the post on or before that date subject to the Production of the evidence to the effect by the applicant.

PART IIIForwarded to the Accounts Officer

( Here indicate the address and signature )……………………… with the remarks that:-i. The particulars furnished by the applicant in Part I have been verified and are correct.ii. Ii. The applicant is eligible to get a fraction of his pension commuted without medical examinationiii. The commuted value of Pension Determined with reference to the Table applicable at present comes to Rs……………………………and iv. The amount of Residual Pension after commutation will be Rs……………………2. The pension papers of the applicant completed in respect were forwarded under this Ministry/Department/Office letter No………………….. dt…………………………….It is requested that the payment of commuted value of Pension may be authorized through the pension payment order which may be issued one month before the retirement of the applicant.3. The receipt of Part-I of this form has been acknowledged in Part-II which has been forwarded separately to this applicant on ……………………………………4. The commuted value of Pension is debitable to Head of Account…………………..

Place Signature

Dated HEAD OF OFFICE

DECLARATION IN TERMS OF ARTICLE 922 (a ) C.S.R.VIDE AMENDMENT LIST NO. 176 OF 1942

Whereas the government has consented provisionally to advance to me the sum of Rs……………..a month, in anticipation of the completion of enquiries necessary to enable the Government to fix the amount of my pension, I hereby acknowledge that in accepting this advance I fully understand that my pension is subject to revision on the completion of the necessary formal enquiries and I promise to base no objection to such revision on the ground that the provisional Pension now to be paid to me exceeds the pension to which I may eventually be found entitled. I further promise to repay any amount advanced to me in excess of the pension to which may be eventually found entitled.

Signature :

Name in Block Letters:

Grade :

A/c No.

Witness

Signature

Name in Block Letters.GradeA/c No. No.

Will be completed by the Controller of Defence Accounts ( Pension ) Allahabad

DECLARATION

I . do hereby declare that any outstanding demands and other Govt. dues, if

remain outstanding against me on the date of my application for Pension/DCRG or come to light

subsequently, the same may please be recovered from my Pension/DCRG payments/Encashment

of leave amount.

Place: Signature

Name:

Date:Grade:

A/C. No :

Office:

BANK DETAILS Annexure-A

1. Name(s) of account holder

M P R A B H U

2. Link Bank name and Address

3. Link Bank BSR Code

4. Paying bank Branch name & Address

5. Paying Bank Branch BSR Code (7 Digit)

6. Bank Account No.

Certified that this branch is authorized for making payment of Pension to Defence Pensioners.

Signature & Seal of Bank

APPLICATION FOR PENSIONER IDENTITY CARD(please enclose a single stamp size photograph)

1.NAME / DESIG /A/C NO. :

2. PER RESIDENTIAL ADDRESS :

3. CONTACT NUMBER (MUST) :

4. BLOOD GROUP ( MUST) :

5. DATE OF BIRTH :

6. DATE OF SUPERANUATION/VRS :

7. POST HELD ON RETIREMINT :

8. LASTPAY/AVE.EMOLUMENTS : ( to be shown in bracket )

9. QUALIFYING SERVICE :

10 PENSION ORIGINALLY SANCTTONED :

l1. PPO No. & DATE :

12. CASH/MRO/DATE (ForRs.125/- only ) :

l3. ADHAAR No. :

PLACE:

DATE:SIGNATURE OF GOVT SERVANT

SPECIMEN SIGNATURE

1.

2.

Thumb and Finger Impressions :

The impression on page 1 is required for permanent record in the Audit office.

A small quantity of printer’s ink should be well rubbed on a tin slab until a very thin even layer is formed. The balls of the thumb and of all the fingers of the left/right hand of the individual after being wiped, should be lain on the inked slab and rolled from side to side ( not rubbed ) until sufficiently inked ( this can be learnt from experience ) and then lightly and carefully rolled on the paper on which the print is to be taken in such a way that the pattern of the whole of the ball of the thumb and fingers from side to side is clearly impressed on ti. It must be specially borne in mind that the side movement either at the time of applying or removing the thumb may cause smudge and spoil the impression. 

REMARKS BY HEAD OF OFFICE

As to character and past conduct of applicant :

(a)Whether the officer is involved in a disciplinary : case/Court of Enquiry or not

Explanation of any suspension or degradation :

Regarding any gratuity or pension already received: by applicant-see Chapter XXI, C.S. Regs. Any other remarks :

Specific opinion by Head of office, whether the service : claimed is established, and should be admitted or not ( see Articles 919 (ii)/917(ii) C.S. Regs )

Station : Signature :

Date : Designation :

After review (x) of the applicant’s record of service, I am of opinion that the pension/gratuity as admissible under the rule should be admitted in full/to the following extent only.

Signature

Signed by or for the authority competent to fill the vacancy

SPECIMAN SIGNATURE IN RESPECT OF -

1…………………………………………

2………………………………………….

3. …………………………………………

HIEGHT AND PERSONNEL IDENTIFICATION MARK IN RESPECT OF

1. HEIGHT - :

2. PERSONNEL IDENTIFICATION :

ATTESTED 

DESCRIPTIVE ROLL DESCRIPTIVE ROLL OF CLAIMANT

i) Sri/Smt. :

i) Date of birth by Christian Era : :

ii) Height: :

iii) Marks of identification: : iv) Signature :

v) Left/Right hand thumb & finger impression: RIGHT HAND LEFT HAND

THUMB THUMB

FORE FINGER FORE FINGER

MIDDLE FINGER MIDDLE FINGER

RING FINGER RING FINGER

LITTLE FINGER LITTLE FINGER

Name of the treasury at whichPayment is desired:

Date:Permanent address of Sri/Smt.

SIGNATURE

SPECIMEN SIGNATURE OR THUMB IMPRESSION

1.

2.

3. ATTESTED