KATY ODISHA: PENSION PAPER, WHICH ARE REQUIRED TO BE SUBMITTED BEFORE RETIREMENT.

FORM 5

[See Rule 59 (1) (c) and 61 (1)

[Also see rules 5(2),12,13(3),14(1) and 15(3) of Central Civil Services (Commutation of Pension)

Rules, 1981]

(Particulars to be obtained by the Head of Office from the retiring

Government servant eight months before the date of his retirement)

Name :
(a) Permanent Account No for Income (PAN) :

(b) Aadhaar No. if available :

Specify a few marks of identification, not less

than two, if possible :

(i) :

(ii) :

4. Height :

5. Address after retirement for future correspondence: -

6. Bank Account No. to which pension is to be credited :

(Joint account either or survivor with spouse)

(In case the Head of Office is satisfied that it is not possible for retiring Government servant to open a joint account for reasons beyond his/her control this requirement may be relaxed)

7. Name of the Branch of Bank through which pension is to be drawn

a. BSR code of the branch :

b. IFSC code of the branch :

8. Indicate whether family pension is also 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.

9. I desire to Commute……….%(up to 40%) of may superannuation pension in accordance with the provisions of the Central Civil Services (Commutation of Pension) Rules, 1981

I am aware that future good conduct of the pensioner/family pensioner shall be an implied condition for every grant of pension/family pension and its continuance.

Enclosures as per check-list are enclosed.

Signature:_________________

Place: _________________ Designation: _________________

Ministry/Department/ Office: _________________

Date: _________________ Mobile No: _________________

E mail ID: _________________

Note 1 : Commutation of pension is optional. Item 9 may be stuck off if the retiring Government servant does not desire to commute a percentage of pension.

Note 2 : A separate application for commutation of superannuation pension in Form 1-A of Central Civil Services (Commutation of Pension) Rules, 1981 is required to be submitted in case the retiring Government servant desires to apply for Commutation of Pension after submission of this form but three months before retirement.

Note 3 : It is in the interest of the Government servant to provide E-mail ID and Mobile number, which facilitates future correspondence.

Check list of Documents to be submitted along with Form 5

Sl No.	Description of documents to be enclosed	Whether enclosed
1. (a) (b)	Two specimen signature (to be furnished in a separate sheet) Additional information (only in case of an illiterate or disabled Government servant):- Two slips each bearing the left hand thumb and finger impressions duly attested may be furnished by a person who is not literate and cannot 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 impression 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 Gazetted Government servant.
2.	Three copies of passport size joint photograph with wife or husband. Where it is not possible 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. Three copies of passport size photograph of disabled child/siblings/dependent parents, if applicable (to be attested by the Head of office)
3.	Details of the family in Form 3
4.	Undertaking in Form 26 for those who served in Security-related or intelligence Organization referred to in rule 8 of the CCS (Pension) Rules, 1972
5.	Written statement for counting of period of service under rule 59(1)(a) if any
6.	Undertaking for refunding any excess payment made by the pension disbursing Bank
7.	Nomination for gratuity. CGEGIS and GPF in Common Nomination Form
8.	Nomination for arrears of Pension and Commuted value of pension (if applied for commutation of pension) in Common Nomination Form

SPECIMEN SIGNATURE

Signature of Applicant Attested by

SPECIMEN SIGNATURE

Signature of Applicant Attested by

IDENTIFICATION MARK

1. Height:_________feet___________Inches

SIGNATURE

Attested by

IDENTIFICATION MARK

2. Height:_________feet___________Inches

SIGNATURE

Attested by
FORM 3

[See Rule 54 (12)]

DETAILS OF FAMILY

Name of the Government Servant :

Designation :

Date of Birth :

Details of the Members of my Family as on :

Sl No, (1)	Name of the Members of Family * (2)	Date of Birth (3)	Relationship with the officer (4)	Marital status (5)	Remarks (6)	Dated signature of Head of Office (7)
1
2
3
4
5
6
7
8

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

Place :

Date :

Signature of Government Servant

Note 1.- The original Form submitted by the Government servant is to be retained. All additional /alterations are to be recorded in this Form under the signature of Head of Office in Col. No. 7, new Form will substitute the original Form. However, the retiring Government servant should submit the details of family afresh along with Form 5.

Note 2. – The details of spouse, all children and parents (whether eligible for family pension or not) and disabled siblings (brothers and sisters) may be given.

Note 3. – The Head of Office shall indicate the date of receipt of receipt of communication regarding addition or alteration in the family in the ‘Remarks’ column the fact regarding disability or change of marital status of a family member should also be indicated in the ‘Remarks’ column.

Note 4. – Wife and husband shall include judicially separated wife and husband.

SIGNATURE OF

HEAD OF OFFICE

Common Nomination Form 1

For Gratuity, GPF and Employees’ Group Insurance Scheme

[See Rule 53 of CCS (Pension) Rules, 1972, Rule 5 of General Provident Fund (CS) Rules, 1960 and Para 19.7 of Employees’ Group Insurance Scheme, 1980]

Head of Office

………………………………..

…………………………………

I, ………………………………………………………… hereby nominate the person/persons mentioned below and confer on him/her/ them the right to receive in the event of my death, to the extent specified below, amount on account of the following:-

i) Any gratuity the payment of which may be authorized under Rule 50 of CCS (Pension) Rules

ii) Amount that may stand to my credit in the General Provident Fund

iii) Any amount that may be sanctioned by the Central Government under the Central Government employees Group Insurance Scheme, 1980

Name, date of birth (DOB) and address of the nominee	Relation ship with employee/ pensioner	Share to be paid to each	If nominee is minor, name, DOB and address of person who may receive the amount on behalf of minor	Name ,DOB and address of alternate nominee in case the nominee under Column(1) predeceases the employee/ pensioner	Relationship with employee/ pensioner	Name, DOB and address of person who may receive the amount if alternate nominee in Col.(5) is a minor	Contingency on happening of which nomination shall become invalid
1	2	3	4	5	6	7	8

These nominations supersede any nominations made by me earlier.

Place and date: Signature of Government servant

Telephone No.

Common Nomination Form 2

For Arrears of Pension and Commutation of Pension

[See Rule 5 of Payment of Arrears of Pension (Nomination) Rules, 1983, Rule 7 of CCS (Commutation of Pension) Rules, 1981]

Pension disbursing Authority,

………………………………..

…………………………………

i) Arrears of Pension

ii) Commuted Value of Pension

Name, date of birth (DOB) and address of the nominee	Relation ship with employee/ pensioner	Share to be paid to each	If nominee is minor, name, DOB and address of person who may receive the amount on behalf of minor	Name ,DOB and address of alternate nominee in case the nominee under Column(1) predeceases the employee/ pensioner	Relationship with employee/ pensioner	Name, DOB and address of person who may receive the amount if alternate nominee in Col.(5) is a minor	Contingency on happening of which nomination shall become invalid
1	2	3	4	5	6	7	8

These nominations supersede any nominations made by me earlier.

Place and date: Signature of Government servant

Telephone No.

Note 1 - Separate copies of nomination Form may be used for nominating different persons for benefits (i) and (ii) above by ticking the intended benefit and striking out the benefit which is not intended to be made

FORM 1- A

FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF SUPERANNUATION PENSION WITHOUT MEDICAL EXAMINATION WHEN APPLICANT DESIRES THAT THE PAYMENT OF THE COMMUTED VALUE OF PENSIONSHOULD BE AUTHORIZED THROUGH THE PENSIONPAYMENT ORDER

(See Rules 5 (2), 12, 13 (3), 14 (1) and 15 (3))

(To be submitted induplicate at lease three months before the date of retirement)

PART – I

The Additional Commissioner (P&V), Central Excise, Customs & Service Tax, Bhubaneswar – I Commissionerate, C. R. Building, Rajaswar Vihar, Bhubaneswar – 751007

(Here indicate the designation and full address of the Head of Office)

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 :-

Name ( in Block letters) :
Father’s name (and also husbands name in

the case of a female Govt. servant) :

Designation :
Name of Office/Dept./Ministry in which

Employed. :

Date of Birth ( by Christian era) :
Date of retirement on superannuation or on

the expiry of extension in service granted

under FR-56 (d) :

Faction of superannuation pension proposed

to be commuted. :

Disbursing authority from which pension is

to be drawn after retirement

(a) Treasure/ Sub – Treasury (name and complete

address of the Treasury / Sub – Treasury

to be indicated ) :

(b) (i) Branch of the nominated nationalized

bank with complete postal address :

(ii) Bank Account No. to which monthly

pension is to be credited each month :

Department / Office :

Place: Signature

Date : Present postal address

Postal address after retirement

PART – II

(ACKNOWLEDGEMENT)

Received from Shri. / Smt._______________________________________________

Designation ____________________ application in Part – I of Form I – A for commutation of a fraction of pension without medical examination.

Place : -

Date :-

SIGNATURE

HEAD OF OFFICE

PART – III

Forwarded to the Accounts officer.

(here indicate the address and designation)_________________________________ with the remarks that –

(i) the particulars furnished by the applicant in Part – I have been verified and are correct

(ii) the applicant is eligible to get a fraction of his pension commuted without medical examination.

(iii) The commuted value of pension determined with reference to the table applicable at present comes to Rs._________ and.

(iv) The amount of residuary pension after commutation will be Rs. ________

2.. The pension papers; of the applicant completed in all respect were forwarded under this Ministry / Department Office Letter No. ______________dated_____________it is requested that the payment of commuted value of pension may be authorized to the Pension Payment Order which may be issued one month before the retirement of the applicant.

10. The receipt of Part – I of this Form has been acknowledged in Part – II which has been forwarded separately to the applicant on _________

11. The commuted value of pension is debitable to Head of Account _______________

Place :-

Date :-

SIGNATURE

HEAD OF OFFICE

G.A.R. 04

(See Rule 180)

RECEIPTED BILL

Received the sum of Rs.____________ (Rupees ________________________________________ ________________________________________________) being the total of entitlement of Rs.________________________________________________ from the insurance Fund and / or of Rs._____________ from the Savings Fund, accrued to ___________

Name ___________________________________________ Designation_________________

Group A/B/C/D under the Central Government Employees Group Insurance Scheme, 1980

Date:_______________________ Signature (s) of Recipient (s)

(NAME IN BLOCK LETTERS)

FOR USE IN DEPARTMENTAL OFFICE

(a) Relevant Bio- data of the member:

1. Type of group of the member (i.e lowest group) viz. D/C/B/A on initially joining the scheme on _____________________(date)

2. Year of acquiring membership of higher group:-

(i) C - 19

(ii) B - 19

(iii) A - 19

(b) Countersigned for payment of Rs._______________________(Rupees_________________

_____________________________________________ ) to claimant (s). Crossed/ Cheque / Demand Draft to be issued in favour of claimants(s)

SIGNATURE

Date :

Designation :

FOR USE IN PAY AND ACCOUNTS OFFICE

Passed for payment of Rs.____________ ( Rupees_________________________________

________________________________________) payment through Cheque(s)/ Demand Draft(s)

______________________________________, Date___________________

PAY AND ACCOUNTS OFFICER

Additional document to be submitted along with pension papers

1) Photo copy of Pass Book (front page)

2) Joint Photograph (3 Nos.)

3) Proof of date of Birth of all family members mentioned in form 3

4) Madate from duly counter signed by the Bank

5) Option for availing CGHS facility or fixed medical allowance

6) Similar details for the pensioner, the specimen signature, personal mark of identification, left hand thumb impression, the proof of age/date of birth and an undertaking from the spouse regarding recovery of excess payment.

SPECIMEN LETTER OF UNDERTAKING BY THE PENSIONER

To Date________

The Branch Manager

_______________________________________________ (Bank)

_______________________________________________(Branch & address)

Dear Sir,

Payment of pension under A/c No.____________________________ through your Bank.

In consideration of your having, at my request, agreed to make payment of pension due to me every month by credit to my account with you. I the undersigned agree and under take to refund or made good any amount to which I am not entitled or any amount which I am or would be entitled. I further hereby undertake and agree to bind myself and my heirs, successor, executors and bank in so crediting my pension to my account under the scheme and to forthwith pay the same to the bank and also irrevocably authorize the bank to recover the amount due by debit to my said account or any other account/deposits belonging to me in the possession of the bank

Yours faithfully,

Signature:

Name:

Address:

Witnesses:

1) Signature: 2) Signature:

Name: Name:

Address: Address:

Date: Date:

SPECIMEN LETTER OF UNDERTAKING BY THE PENSIONER

To Date________

The Branch Manager

_______________________________________________ (Bank)

_______________________________________________(Branch & address)

Dear Sir,

Payment of Family Pension under A/c No.____________________________ through your Bank.

In consideration of your having, at my request, agreed to make payment of Family Pension due to me every month by credit to my account with you. I the undersigned agree and under take to refund or made good any amount to which I am not entitled or any amount which I am or would be entitled. I further hereby undertake and agree to bind myself and my heirs, successor, executors and bank in so crediting my pension to my account under the scheme and to forthwith pay the same to the bank and also irrevocably authorize the bank to recover the amount due by debit to my said account or any other account/deposits belonging to me in the possession of the bank

Yours faithfully,

Signature:

Name:

Address:

Witnesses:

1) Signature: 2) Signature:

Name: Name:

Address: Address:

Date: Date:

KATY ODISHA

INDIA-AMERICA-BRITISH

Thursday, 5 February 2015

PENSION PAPER, WHICH ARE REQUIRED TO BE SUBMITTED BEFORE RETIREMENT.

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