CS-64A
form for assessing pension and gratuity
1. Name of the Applicant
2. Father’s name (and also husband’s name in the case of
female employee)
3. Date of birth
4. Date of birth (by Christian Era)
5. Permanent residential address showing village,
town, distt. and state
6. Present or last appointment including name of establishment :
(i) Substantive
(ii) Officiating, if any
7. Date of beginning of qualifying service in K.V.S.
8. Date of ending of service in KVS
9. (i) Particulars of service, if any under Central
Govt. etc. before joining KVS
(ii) Details of pro-rata retirement benefits already
received for that service
(a) Pension
(b) Gratuity
(c) Management share of CPF
(iii) Details of pro-rate retirement benefits already
transferred for counting that service in the KVS
(a) Amount equivalent of pension
(b) Gratuity
(c) Management share of CPF
10. Class of pension applicable
11. The date on which action initiated to :
(a) Obtain the ‘No Demand Certificate’ from the Authority controlling allotment of residential accommodation as provided in Rule 57;
(b) assess the service and emoluments qualifying for pension as provided in Rule 59; and
(c) assess the Sangathan dues other than the dues relating to the allotment of accommodation as provided in Rule 73 (1)
12. Details of omissions, imperfections or deficiencies in the service book which have been ignored under Rule 59 (1) b (ii)
13. Total length of qualifying service (for the purpose of adding towards broken periods, a month is reckoned as 30 days)
14. Periods of non-qualifying service From To
(i) Interruption in service condoned under Rule 28
(ii) Extraordinary leave not qualifying for pension
(iii) Period of suspension not treated as qualifying
(iv) Any other service not treated as qualifying
Total
15. Emoluments reckoning for gratuity
16. Average emoluments
*Emoluments drawn during the last ten months of service
Post Held From To Pay Persional Pay or Average
Special Pay Emoluments
1 2 3 4 5 6
17. Date on which form 63 has been obtained from the applicant. (To be obtained eight months before the date of retirement of sangathan employee)
18. Date from which pension is to commence.
19. Have any departmental or judicial proceedings been instituted/contemplated against the applicant before retirement.
20. Details of Sangathan dues recoverable out of gratuity:
(a) Licence fee for the allotment of office accommodation etc.
(b) H.B. Advance
(c) other dues
21. Whether nomination made for Death-cum-retirement Gratuity
22. Emoluments reckoning for the family pension
23. Height
24. Identification Marks
25. Place of payment of pension through S.B.I.
26. Name of Branch & A/c No.
Signature of the Head of Office
______
*(i) In a case where the last ten months include some period not to be reckoned for calculating average emoluments an equal period backward has to be taken for calculating average emoluments.
(ii) The calculation of average emoluments should be based on actual number of days contained in each month.