Sub: Submission of Revised Pension Proposal As Per G.O Ms.No.105 Fin (Paycell)

From

…………………………

………………………….

…………………………

…………………………….

The Accountant General,

Chennai- 600 018

Through proper channel

Sir,

Sub: Submission of revised pension proposal as per G.O Ms.No.105 Fin (Paycell)

dept dated 07/02/06– Regarding

Ref:

1 Letter No.XI /V /574 from O/O The Accountant General (A & E). Tamilnadu,

Chennai

2 Admissibility report No. with Date PXI/V/C36-1175/450/05-06 dated 12/05

With reference to the letter cited, I am submitting the pension proposal with merger benefits.

I am going to retire from service with effect from ………. My date of birth is ………………. I request that necessary action may kindly be taken for the sanction of the pension, Commutation amount, gratuity and family pension admissible to me from the date of my retirement.

I desire to draw my pension from the Pay and Accounts Office (pension), College Road, Chennai –600 006. I hereby declare that I have neither applied for nor received any pension or gratuity in respect of my portion of the service qualifying for this pension and in respect of which pension and gratuity are claimed herein nor shall I submit an application hereafter without quoting a reference to this application and the orders may be passed thereon.

I am governed by Rule 54 of the Tamilnadu Pension Rules 1976 and that the details of my family already furnished by me in Form 03 are complete and up to date.

I enclose herewith in triplicate the following:

Form 5 (Part I & II)

Specimen signature

Pass port size joint photos

Particulars of height and identification marks

Left hand thumb and finger impressions

List of family members

Declaration

Requisition letter for extension of service

Nomination for family pension

My present address:

…………………………

After retirement:

………………………………

Chennai- 600 039 Yours Faithfully,

Dated: .

Signature of the Principal

FORM 5

Particulars to be obtained by the Head ofOffice from the Retiring Government ServantONE YEARbefore the date of his Retirement

(G.O.Ms.No.989, Finance (B.G.III) Department, dated 10.9.86)

PART I

1. / Name / :
2. / (a) Date of Birth
(b) Date of retirement
(c) Designation at the time of retirement / :
3. / Two specimen signatures duly attested (to be furnished in a separate sheet / : Enclosed
4. / *Three copies of the pass port size joint photograph with wife or Wife (to be attested by the Head of Office) / : Enclosed
5. / **Two slips showing the particulars of height and personal identification marks duly attested / : Enclosed
6. / Present address / :,
7. / ***Address after retirement / :,
8. / Name of the Treasury / : Pension Pay Office,
College Road,
Chennai –600 006
9. / Details of the Family in Form 3 / : Furnished
10. / Class of pension / :Retirement on superannuation
11. / Amount of pension authorised / : To be filled in by the A.G’s office
later
12. / Whether pension is proposed to be commuted / : Yes
13. / @@ If so, fraction of pension to be commuted. / : 33 1/3 %
13(a) / Commutation value / = Rs.
Date : / Signature :
Place : / Designation :
Department/Office :

Two slips each bearing the left hand thumband finger impressions duly attested by the Head of Office may be furnished byaperson who is not literateenough to sign his name. If such a Government Servant on account of physical disability is unable to give left hand thumb and finger impression he may give thumb and finger impressions of the right hand. Where a Government Servant has lost both the hands, he may give his the impressions. Impression should be duly attested,by the competent authority.

*Two copies of passport size photo of self only need be furnished.

i. If the Government servant is governed by rule 49 of the Tamilnadu Pension Rules, 1978 and is unmarried or a widower/widow.

ii. If the Government Servant is governed by rule 50 of the Tamilnadu Pension Rule, 1978.

iii. Where it is not possible for a Government Servant to submit a photo with wife or Wife he or she may submit separate photographs. The photos shall be attested by the Head of Office.

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

***Any subsequent change of address should be notified to the Head of Office and Audit officer.

@@The applicant should indicate the fraction of the amount of monthly pension (subject to a maximum of one-third thereof) which he desires to commute and note the amount in rupees.

Signature of the Principal

FORM 5

PART II

1. Forwarded to the Accountant-General, Tamilnadu 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. …………..

iv. The amount of residuary pension after commutation will be Rs.9,150/-

2. It is requested that further action to authorise the payment of the

amounts of commuted value of pension may be taken as in rule 15 of the

Tamilnadu (Commutation of Pension Rules).

3. The commuted value of pension is debitable to Head of Account.:

Govt.Account 2071 Pension and other retirement benefits

A slip containing 3 specimen signatures of ……………….. is enclosed

A slip containing passport size photograph of ………………… is enclosed

A slip containing details of family members of ………………… is as under

Sl.No. / Name of the family
members / Relationship / Age / Married or Unmarried
1.
2.
3.

Place: Chennai-600039

Date: Signature of the Head of Office.

Specimen signature of

/ Countersigned/

Place: Chennai-39 Signature of the Principal

Date:

PASSPORT SIZE JOINT PHOTOGRAPH WITH WIFE OF

Place : Chennai-39

Date :

Applicant

/Countersigned/

SIGNATURE OF THE PRINCIPAL

PARTICULARS OF HEIGHT AND IDENTIFICATION OF

1. Height : cm

2. Identification marks : (i)

(ii)

Place: Chennai – 39

Date:

Applicant

/ Countersigned/

Signature of the Principal

LEFT HAND THUMB AND FINGERS IMPRESSION OF:

Little Finger Ring Finger Middle Finger Fore Finger Thumb

Place: Chennai – 39

Date: Applicant

/ Attested /

Signature of the Principal

FORM – 3

Details of Family

1. Name of the Government Servant :

2. Designation :

3. Date of birth :

Details of Members of my family are as follows

Sl.No. / Name of the member of family / Date of birth / Relationship / Marital Status
1.
2.
3.

Place: Chennai – 39

Date:

Applicant

/ Countersigned /

Signature of the Principal

Declaration of Consent for Recoveries

I, …………. hereby certify that I am willing to make good any loss caused to Government by way of over-drawal of my pay, allowance or leave salary or other admitted and obvious dues as a result of negligence or fraud, if any, on my pension.

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 this pension and in respect of which pension and Gratuity herein nor will I submit an application hereafter without quoting a reference to this application and the order which may be passed herein.

I, …………… hereby agree for the recovery from my pension and Gratuity/ Family pension of any amount, which may be due and recoverable from me.

I, ……………. hereby declare that no disciplinary action is pending against me.

Place: Chennai-600 039

Date:

Applicant

/Countersigned/

Signature of the Principal

CALCULATION SHEET

Name:

Particulars / From / To / Total / Grand Total
Y / M / D / Y / M / D
i) Length of Service -
Govt.
ii) EOL not Qualifying
for Pension
iii) Net Qualifying
service
iv) No. of Half Years of
Qualifying service

Lat Pay Drawn

Emoluments for the last month= B.Pay Rs……………-+DP ………… =

Pension

AE x Qual. No. of half Years 66/ 66 x 1/2 = ………… x 1/2 = Rs.

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Amount of Death cum Retirement Gratuity

Pay last drawn:

= Basic Pay: Rs. …….. + D.Pay Rs. ………+ DA: Rs……….. = Rs.

DCRG= Rs……… X 66/ 4= Rs…………….- restricted to Rs.3,50,000/-

Amount of Family Pension:

30% of Pay Last drawn Rs. 28040/- = Rs.

Enhanced equal to 50% of salary last drawn = Rs………… X ½ X = Rs.

Amount of Commutation Pension:

331/3 % of Pension of Rs ………. X 10.46 X 12 = Rs.

------

Date of retirement:

Date of first appointment

Date of Birth

SIGNATURE OF THE PRINCIPAL

Form – 7

FORM FOR ASSESSING PENSION AND GRATUITY

Part – I

1. Name of the Government Servant :

2. Father’s Name :

3. Date of Birth :

4. Religion and Nationality :

5. Permanent Residential Address :, .

6. Present or last appointment

including name of establishment

(i) Substantive :

(ii) Officiating : Nil

7. Date of beginning of service :

8. Date of ending of service :

9. (i) Total period of Military

service in which Pension/

Gratuity was sanctioned : Nil

(ii)Amount and nature of pension/

Gratuity received for the

Military service : Nil

10. Amount and nature of any Pension/

Gratuity received for previous civil

Service : Nil

11. The date on which action was

initiated to

(i) Obtain the “No demand

Certificate” from the

Department in charge of

building as provided in

Rule 58 : Nil

(ii) Assess the service and

emoluments qualifying for

pension as provided in Rules

57&61 : Nil

(iii) Assess the Government dues

other than the dues relating to

the allotment of Government

accomodation : Nil

12. Details of commission, imperfection or

deficiencies in the service book which has

been ignored : Nil

13. Length of qualifying service : Y M D

Date of retirement :

Date of appointment :

14. Periods of non-qualifying service

(i) Interruption(s) : Nil

(ii) Extraordinary leave not qualifying

for pension : Y M D

(iii)Period of suspension not treated as

qualifying : Nil

(iv) Any other service not treated as

qualifying : Nil

–––––––––––––––––––

Y M D

Total : 0 01 16

–––––––––––––––––––

15. Emoluments reckoning for Gratuity : Pay:…….. +DP ……..+DA: ……..

= Rs ………./-

16. Pay last drawn :B.Pay Rs………+D.Pay Rs……..

= Rs………./-

17. Date on which the Government servant

applied for Pension in Form-3 : …………

18. Proposed Pension : Rs. ………/-

19. Proposed/Death cum Retirement

Gratuity : Rs.3,50,000/-

20. Date from which Pension is to commence :

21. Proposed amount of Provisional Pension

if departmental or judicial proceeding

is initiated against the Government

Servant before retirement : Nil

22. Details of Government dues referred to in

Rule 70 recoverable out of Gratuity : Nil

23. Whether nomination is made for

(i) Death cum Retirement Gratuity : Attached in the SR

(ii)Non-Contributory Family Pension if

applicable : Nil

24. Whether Contributory Family Pension is

applied to the Govt. Servant and, if so,

(i) Emoluments reckoning for Family

Pension : B.Pay Rs……..+

D.Pay Rs…….. = Rs………./-

(ii) The amount of the Family Pension

becoming payable to the Wife of

Govt. Servant in the event of his

death after retirement : Rs………..

(iii) Complete and up to date details of

Family as given in Form 3 :

S.No / Name of the member of the family / Relationship with the Govt. Servant / Age / Date of birth / Marital status
1
2.
3.

25. Height : cms

26. Identification marks (i).

(ii)

27. Place of payment of Pension/

Gratuity : The Pay and accounts office for

pension, College Road,

Chennai –600 006

28. Head of Account to which Pension

and Gratuity are debitable : Govt. Account 2071 pension and other

retirement benefits

Applicant

Place: Chennai- 39

Date:

Signature of the Principal

This is to certify that no disciplinary action is pending against

Signature of the Principal

FORM E

NOMINATION FOR FAMILY PENSION

I hereby nominate my …………….. ………………………… ……………… …………… ……………………………………………………………………………, , to receive my family pension in the event of my death.

Place: Chennai-39 Signature of the Government Servant

Date:

Witnesses to Signature Name & Designation

Signature of Head of Office