Rule 1 — CCS

1. Name of the Pensioner(in block letters) 2. Date of retirement 3. Particulars of the Ministry/Department/Office in which the pensioner served during the last five years preceding retirement (with duration) 4. Post held at the time of Retirement and period for which held 5. Pay scale/Pay Band & Grade Pay of the post and the Pay drawn by the officer at the time of retirement 6. Pensionary benefits

(a) Gross monthly Pension sanctioned/expected

(b) Commutation, if any.

(c) Gratuity, if any

B. Particulars of proposed employment

1. Date of receipt of application in Office/Ministry/Department

These nominations supersede any nominations made by me earlier.

1. Central Civil Services (Pension) Rules, 2021 for Gratuity

1. The original Form submitted by the Government servant is to be retained. All additions/alterations are to be communicated by the Government servant/pensioner along with the supporting documents and the changes shall be recorded in this Form under the signature of Head of Office in column (7). No new Form will substitute the original Form. However, the retiring Government servant should submit the details of family afresh along with Form 6.

S.No Name

(s) and Address of members of family Relationship with the Pensioner Martial Status in case of son/ daughter Whether the child is physically handicapped

1. Name of the Pensioner (as recorded in PPO) 2. Full present Address 3. Date of Retirement 4.

(i) PPO No. & Date

(ii) Name of PPO Issuing Authority 5. Name of the Pension Disbursing Authority

(i) Station

(ii) Treasury/DPDO/PAO/PSB, as the case may be

(iii) Bank Branch with full Address and A/c. No.

6.

(a) Details of family (as already available in records)

(b) If the application is for inclusion of post-retiral spouse, the date of death/divorce of the previous spouse (Self - attested copies of death certificate/ divorce decree to be enclosed)

List of Documents to be submitted with Form 5 1. Copy of PPO. 2. Three copies of passport size joint photograph with spouse. 3. Photocopy of the first page of Pass Book of the Joint Bank Account (with spouse) in which the pension is to be credited 4. Self -attested copies of death certificate/ divorce decree 5. Self-attested copy of marriage certificate 6. Birth certificate of child borne after retirement. 7. Disability certificate of child (If the child suffers from a disability)

1. Detail of Government servant:

Name Designation/ Rank Date of birth Date of retirement Ministry/Department/Office PAN No. Aadhaar No.*(voluntary) Nationality 2. Address after retirement for future correspondence: Flat/House No./Bldg. Name Street/Locality Village & Post Office/Block City & District State Pin Code Telephone No. (If any) Mobile No. E-mail ID 3. Details of Bank through which Pension is to be drawn: Type of A/c A/c No. Branch IFS Code

Note 1: Please attach a copy of the first page of passbook/cancelled cheque/document showing the name of Account Holder. (The name should be the same in the bank account, this form and the office records.)

Note 2: Please ensure that the Government servant is the Primary Account holder in the Joint Account

Note 3: In case Head of Office is satisfied that it is not possible for the retiring Government servant to open a joint account for reasons beyond his/her control, this requirement may be relaxed.

Disabled child/ children (Disability certificate to be attached for co-authorisation.) Dependent parents. Disabled siblings. (Disability certificate to be attached for co-authorisation.)

1. Name of the retiring Government servant Nationality Name of Mother/Father Mother Father *Aadhaar No. (if available) PAN no. Date of Birth (DD/MM/YYYY) 2. Post held at the time of retirement: -

(a) Name of the office

(b) Post held

(c) Level of pay in the pay matrix (D)Basic pay

(e) Whether the appointment mentioned above was under Government or outside the Government on foreign service terms

(f) Level of pay /basic pay in the pay matrix of the post in the parent department Whether declared substantive in any post under the Central Government 3. Date of beginning of service (DD/MM/YYYY) 4. Date of ending of service (DD/MM/YYYY) 5. Cause of ending of service (please tick one)

(a) Superannuation (Rule 33)

(b) Voluntary retirement on being declared surplus (Rule 34)

(c) Voluntary retirement [under Rules 43 or FR 56 (k)]

(d) Premature retirement at the initiative of the Government [ Rule 42 or FR 56

(j) ]

(e) Permanent absorption in State Government/ public sector undertaking/autonomous body (Rules 35, 36, 37 or 38)

(f) Invalidation on medical grounds (Rule 39)

(g) Compulsory retirement (Rule 40)

(h) Dismissal/Removal from service (Rules 24 and 41) 5.A. 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 (Please see Rule 40) 5.B.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 (Please see Rule 41) 6. 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 (Rule 20)

(d) If answer to

(c) above is in the affirmative, whether the terminal benefits have been refunded

1. Whether retiring Government servant is an allottee of Government accommodation 2. The date on which action initiated to obtain the 'No demand certificate from the Directorate of Estates as provided in Rule 55. 3. Date of receipt of 'No Demand Certificate' from Directorate of Estates 4. Date on which intimation regarding any recovery/withholding of amount from gratuity received from Directorate of Estates 5. If retiring Government servant is not an allottee of Government office(DD/MM/YYYY) 6. Date on which a certificate regarding the length of qualifying service and the emoluments/average emoluments proposed to be reckoned for retirement gratuity and pension was provided to the Government servant. (DD/MM/YYYY) 7. Whether any objection received from the Government servant on the above certificate 8. Whether the objection has been resolved to the satisfaction of Government servant 9. Whether nominations made in common nomination forms for

(i) Death gratuity/retirement gratuity (ii)Payment under Central Government Employees' Group Insurance Scheme

(iii) Amount of General Provident Fund, if applicable (iv)Arrears of pension (v)Commuted value of pension (if applicable) 10.(i)Has the retiring Government servant worked in any of the organisations mentioned in subrule 4 of Rule 7 of the Central Civil Services (Pension) Rules, 2021 (ii)If yes, whether an undertaking in Format 1 has been obtained along with Form 6 and placed on record 11. tallying with service records Yes No 12. Disbursement of commuted value of pension PAO Disbursing Authority

PART-II (Account Authorisation (by Accounts Officer)

(b)Percentage of family pension to be paid to spouse, if the family pension is to be shared with other members of the family (e.g. children from a wife who is not alive or children from a divorced wife)

(c) Names and relationship of other family members, referred to in

(b) above.

(d) Name of family member to be co-authorised (i.e. disabled child/dependant parent/disabled sibling) G. Head of account to which the amount of pension, retirement/death gratuity and family pension are to be debited

1. Name 2. Designation 3. Date of birth 4. Level of pay in the pay matrix 5. Basic pay 6 Date of entry in the Government service(DD/MM/YYYY) 7.Date of retirement (DD/MM/YYYY) 8. Length of qualifying service reckoned for pension/gratuity(as indicated in PPO) 9(a). Emoluments for pension 9(b). Emoluments drawn during the last ten months 9(c). Average emoluments 10. Emoluments or average emoluments, whichever is more beneficial for pension (as indicated in PPO) 11. Pension admissible (if qualifying service is ten years or more) calculations to be shown as follows :- Emoluments or average emoluments/2 12. Emoluments for gratuity (as indicated in PPO) 13. Retirement gratuity admissible: calculation to be shown as follows :- Emoluments/4 x Qualifying Service (In completed six monthly periods, not exceeding 66.) 14. Pay for family pension (as indicated in Pension Payment Order) 15. Family pension admissible (calculation to be shown as follows) :-

PENSION CALCULATION SHEET Signature of Accounts Officer

PART-I (To be filed by Head of Office)

(a) Ordinary family pension : Pay x 30% (subject to prescribed minimum and maximum)

(b) Enhanced family pension: Pay /2 (Subject to prescribed minimum and maximum) 16. Details of Commutation of Pension, If any

(a) The percentage of pension commuted

(b) Amount of monthly pension commuted

(c) Commuted value of pension

(d) Amount of residuary pension after deducting commuted portion 17. Amount of Fixed Medical Allowance, if admissible

Signature of the Head of Countersigned by PAO

1. Name of the retiring Government servant Name of Mother Father Mother Father *Aadhaar No. (if available) PAN no. Date of Birth DDMM-YYYY 2. Post held at the time of retirement: -

(a) Name of the office

(b) Post held

(c) Level of pay in the pay matrix

(d) Basic pay

(e) Whether the appointment mentioned above was under Government or outside the Government on foreign service terms

(f) Level of pay /basic pay in the pay matrix of the post in the parent department Whether declared substantive in any post under the Central Government 3. Date of beginning of service (DD/MM/YYYY) 4. Date of ending of service (DD/MM/YYYY) 5. Cause of ending of service (please tick one)

(a) Superannuation (Rule 33)

(b) Voluntary retirement on being declared surplus (Rule 34)

(c) Voluntary retirement [under Rules 43 and FR 56 (k)]

(b) and Rule 28 (c)]

(v) Periods of foreign service with United Nation Bodies for which no pension contributions are payable/paid (Rule 29)

(vi) Any other period not treated as qualifying service (give details)

(d) Additions to qualifying service :-

(i) Civil service (Rule19)

(ii) Military service (Rule 20)

(iii) Benefit of service in a State Government/ Autonomous Body (Rule 13/Rule14) Temporary status service (Rule 15) (e)Net qualifying service(a b c + d)

(f) Qualifying service expressed in terms of completed six monthly periods (Period of three months & above is to be treated as completed six monthly period (Rule 44 and Rule 45) 7. Emoluments :-

(a) Emoluments in terms of Rule 31

(b) Emoluments drawn during ten months preceding retirementFrom (DD/MM/YY YY) To (DD/MM/YY YY)

Note: 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 may be mentioned in items

(a) and

(b) above (Rule 32)

(c) Average emoluments (Rule 32)

(d) Emoluments or average emoluments (whichever is higher) to be reckoned for pension (Rule 44) (e)Emoluments reckoned for retirement gratuity (Rule 45)

(f) Pay reckoned for family pension (Rule 50) 8. Proposed Pension Details:-

(a) Amount of pension/service gratuity at full rates (Rule 44)

(b) Amount of retirement gratuity at full rates (Rule 45)

(c) Whether any part of pension or gratuity to be withheld/withdrawn on conclusion of departmental/judicial proceedings under Rule 8 (a)(i)]

Note: In the event of death of pensioner, the family pension at enhanced rate shall be payable for a period of seven years, or for a period up to the date on which the retired deceased Government servant would have attained the age of 67 years had he survived, whichever is less. 11. Name of the family member

(s) to whom family pension is to be authorized in Pension Payment Order (a)Name of the Spouse

(b) Percentage of family pension to be paid to spouse, if the family pension is to be shared with other members of the family (e.g. children from a wife who is not alive or children from a divorced wife)

(c) Names and relationship of other family members, referred to in

(b) above. 1 2 3

(d) Name of family member to be coauthorised (i.e. disabled child/dependant parent/disabled sibling) 12. Commutation of pension :-

(a) The percentage of pension commuted

(b) Amount of monthly pension commuted

(c) Commuted value of pension

(d) Amount of residuary pension after deducting commuted portion Post-retirement address of the retiree e-mail ID, if any Mobile number

Note: Commuted part of pension will be restored after 15 years from the date of payment of commuted value of pension. PART-II (Account Authorisation (by Accounts Officer)

Date of receipt of pension papers by the Accounts Officer from Head of Office (DD/MM/YYYY) Entitlements admitted - A. Length of qualifying service B. Pension -

(i) Class of pension

(ii) Amount of monthly pension

(iii) Percentage of pension to be withheld / withdrawn under Rule 8

(iv) Amount of pension payable after deduction of the amount withheld / withdrawn

(v) Period for which pension is to be withdrawn / withheld

(vi) Date of commencement

(vii) Amount of provisional pension paid (Statement of provisional pension paid every month to be attached) C. Commutation of pension -

(i) Portion of pension commuted, if any

(ii) Commuted value of portion of pension commuted, if any

(iii) Residuary pension after commutation

(iv) Date from which reduced pension is payable (DD/MM/YYYY)

(v) Date of restoration of commuted portion of pension (subject to the pensioner continuing to live) (DD/MM/YYYY) D. Retirement/Death Gratuity -

(i) Total amount of gratuity

(ii) Percentage of gratuity to be withheld under Rule 8

(iii) Amount of gratuity after deduction of amount withheld

(iv) Amount to be adjusted towards arrears of licence fee for Government accommodation and licence fee for retention of Govt. accommodation beyond retirement (Rule 68(1) and 68(4)

(v) Amount intimated by Directorate of Estates for being withheld on account of unassessed licence fee (Rule 68(5))

(vi) Amount to be adjusted towards Government dues other than those pertaining to Government accommodation (Rule 69)

(v) Net amount to be released immediately E. Amount and period of Family pension Amount Period

(i) At enhanced rate (ii)At normal rate F. Name of the family member

(s) to whom family pension is to be authorized in Pension Payment Order (a)Name of the Spouse

(b) Percentage of family pension to be paid to spouse, if the family pension is to be shared with other members of the family (e.g. children from a wife who is not alive or children from a divorced wife)

(c) Names and relationship of other family members, referred to in

(b) above. 1 2 3

(d) Name of family member to be co-authorised (i.e. disabled child/dependant parent/disabled sibling) G. Head of account to which the amount of pension, retirement/death gratuity and family pension are to be debited H. Whether any order affecting pension/ gratuity issued under Rule 8 of CCS (Pension) Rules. Yes No If so, details thereof

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1. Name 2. Designation 3. Date of birth 4. Level of pay in the pay matrix 5. Basic pay 6 Date of entry in the Government service (DD/MM/YYYY) 7.Date of retirement (DD/MM/YYYY) 8. Length of qualifying service reckoned for pension/gratuity(as indicated in PPO) 9. Emoluments drawn during the last ten months 10. Emoluments or average emoluments, whichever is more beneficial for pension (as indicated in PPO) 11. Pension admissible (if qualifying service is ten years or more) calculations to be shown as follows :- Emoluments or average emoluments/2 12. Amount of pension withheld/withdrawn 13. Amount of pension payable 14. Emoluments for gratuity (as indicated in PPO) 15. Retirement gratuity admissible at full rates: calculation to be shown as follows :- Emoluments/4 x Qualifying Service (In completed six monthly periods, not exceeding 66.) 16. Amount of Retirement Gratuity to be withheld/withdrawn 17. Amount of Retirement Gratuity payable 18. Pay for family pension (as indicated in PPO) 19. Family pension admissible (calculation to be shown as follows) :-

(a) Ordinary family pension : Pay x 30% subject to prescribed minimum and maximum

(b) Enhanced family pension: Pay /2 [Subject to prescribed minimum and maximum] 20. Details of Commutation of Pension, If any

(a) The percentage of pension commuted

(b) Amount of monthly pension commuted

(c) Commuted value of pension

(d) Amount of residuary pension after deducting commuted portion

(Retired/retiring Govt. servant)

PENSION CALCULATION SHEET

Photograph

(s) of the Family member

(s) to be coauthorised

1. Details of Government servant/Pensioner : Name Office/Dept./Ministry Nationality Date of retirement (DD/MM/YYYY) Date of death (DD/MM/YYYY) PPO No. (If issued) 2. Details of primary/existing family pensioner : Name Relationship with deceased Government servant/pensioner PPO No. 3. Details of family member to be co-authorised for family pension i.e. Permanently Disabled Child/Dependent Parents / Permanently Disabled Sibling: Name Date of birth (DD/MM/YYYY) Aadhaar No. *(voluntary) PAN Relationship with deceased Govt. servant Personal marks of identification Signature/left hand Thumb impression Whether in receipt of any other pension/family pension. If so, particulars and source from which being drawn 4. Postal address of family member to be co-authorised for family pension: Flat/House No./Bldg. Name Street/Locality Village & Post Office/Block City & District State Pin Code Telephone /Mobile No. E-mail ID 5. In case the family member to be co-authorised is minor or suffering from disorder or disability of mind, including mental retardation, details of guardian/ nominee, wherever applicable: Name Date of Birth (DD/MM/YYYY) Aadhaar No. *(voluntary) PAN Relationship with minor/ mentally disabled family member Relationship with the Government servant /pensioner Postal address of guardian/nominee: Flat/House No./Bldg. Name Street/Locality Village & Post Office/Block City & District State Pin Code Telephone /Mobile No. E-mail ID 6. Details of Bank account of family member to be co-authorised (Optional): A/c No. (Optional) IFS Code

Signature or left hand thumb impression of the Government servant/Pensioner/family pensioner Address..........................................................................................................

Notes:-

(i) If more than one family member are proposed to be co-authorised for family pension, photographs and details in item 3 to item 6 above in respect of all such family members may be given in separate sheets with this Form

(ii) The name

(s) of permanently disabled child/children/siblings and/or dependent parents shall be added in the PPO only if there is no other eligible prior claimant for family pension

(iii) The co-authorisation shall become invalid in case any other member of family becomes entitled to family pension prior to the co-authorised family member.

List of Documents to be submitted with Form 8 in respect of each family member who is proposed to be coauthorised for family pension.

1. Two specimen signatures (to be furnished in a separate sheet) .If the member of the family cannot sign his/her name then he/she is required to put the impression of his/her left/right thumb etc. on the document in lieu of specimen signature. 2. Proof of identity. 3. Proof of relationship with the deceased Government servant/pensioner. 4. Two copies of self attested passport size photographs of the member of the family. 5. Certificate of age showing the dates of birth. The certificate should be from the municipal authorities or from the local panchayat or from the head of a recognized school or Central/state board of education. 6. Two specimen signatures of guardian (to be furnished in a separate sheet if the member of the family is minor or suffering from mental disability) 7. If the guardian cannot sign his/her name then he/she is required to put the impression of his/her left/right thumb etc. on the document in lieu of specimen signature. 8. A copy of Photo ID proof of the guardian along with proof of Permanent Address. 9. Two self attested copies of passport size photograph of the guardian/nominee 10. Last Income Tax Return failing which Certificate from SDM failing which any other document regarding income in support of the claim for family pension. 11. Copy of the first page of the Pass Book or cancelled cheque or any other document showing name and account number in which the family pension is to be credited. (Name of the claimant in the form and in the bank account should be the same)

(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 with one guardian for all of them, the guardian should claim gratuity in one Form on their behalf)

1. Details of deceased/missing Government servant:

Name Date of death (DD/MM/YYYY) Date from which missing (DD/MM/YYYY) Office/Department/Ministry in which the deceased/missing Government servant served last Date of lodging report with Police (in case of missing Government servant only) (DD/MM/YYYY) Nationality

1. Details of deceased/missing Government Servant/Pensioner (To be filled only if a Government servant/pensioner has died or gone missing)

Name Office/Dept./Ministry Nationality Date of retirement (in case of pensioner) (DD/MM/YYYY) Date of death (in case of death of Government servant/pensioner (DD/MM/YYYY) Date from which missing (in case of missing Government servant/ pensioner)(DD/MM/YYYY) Date of lodging of report with Police (In case of missing Government servant/pensioner) (DD/MM/YYYY) PPO No. (If issued)(in case of pensioner)

List of Documents to be submitted with Form 10 1. Two specimen signatures (to be furnished in a separate sheet) .If the claimant cannot sign his/her name then he/she is required to put the impression of his/her left/right thumb etc. on the document in lieu of specimen signature. 2. Proof of identity. 3. Proof of relationship with the deceased/missing Government servant/pensioner 4. Two copies of self attested passport size photographs of the claimant. 5. Details of family in Form 4. 6. Undertaking for refunding any excess payment made by the pension disbursing bank in Format 9. 7. Certificate

(s) of age showing the dates of birth of the children. The certificates should be from the municipal authorities or from the local panchayat or from the head of a recognized school or Central/state board of education. 8. Two specimen signatures of guardian (to be furnished in a separate sheet if the claimant is minor or suffering from mental disability) 9. If the guardian cannot sign his/her name then he/she is required to put the impression of his/her left/right thumb etc. on the document in lieu of specimen signature. 10. A copy of Photo ID proof of the guardian along with proof of Permanent Address. 11. Two self attested copies of passport size photograph of the guardian/nominee 12. Copy of Pension Payment Order of previous pensioner/family pensioner. 13. Copy of death certificate of Government servant/pensioner/previous family pensioner , if applicable 14. Copy of document regarding ineligibility of previous family pensioner, if applicable 15. Copy of report lodged with police in respect of missing Government servant or pensioner or previous family pensioner.(In case of missing pensioner/family pensioner only) 16. Copy of the report from the police that the Government servant could not be traced so far despite all efforts made (In case of missing pensioner/family pensioner only) 17. Indemnity Bond in Format 8 (In case of missing pensioner/family pensioner only) 18. Last Income Tax Return failing which Certificate from SDM failing which any other document regarding income in support of the claim for family pension (Not applicable in the case of spouse). 19. Copy of the first page of the Pass Book showing name and account number in which the family pension is to be credited. (Name of the claimant in the form and in the bank account should be the same) 20. If the claimant is a widowed/divorced daughter or a disabled child/sibling, document in support of the eligibility of the claimant (i.e death certificate of husband in the case of widowed daughter/divorce decree in the case of divorced daughter/disability certificate in the case of a disabled child) 21 Form 8, if a family member is proposed to be co-authorised for family pension.

Part I Section I 1. Details of deceased/missing Government servant:

(a) Name

(b) Nationality (c)Religion

(d) name Name

(f) Date of birth(DD/MM/YYYY)

(g) Date of death (in the case of death of Government servant) (DD/MM/YYYY) (h)Date from which missing (in the case of missing Government servant) (DD/MM/YYYY)

(i) Date of lodging of report with police (in the case of missing Government servant) (DD/MM/YYYY)

(j) Date up to which pay and allowances/leave salary has been paid (in the case of missing Government servant) (DD/MM/YYYY) 2. Post held at the time of death /disappearance:-

(a) Name of the office

(b) Post held substantively

(c) Officiating post

(d) Level of pay in the pay matrix

(e) Basic Pay

(f) In case the last post was held outside the Government on foreign service terms-

(i) Level of pay of the post held in the parent department

(ii) Basic pay

(g) Total period of military service, if any, for which pension and/or gratuity was sanctioned

(h) Amount of any pension/gratuity received for the military service

(i) Nature of any pension/gratuity received for the military service 3. Date of beginning of service (DD/MM/YYYY) 4. Date of death/disappearance (DD/MM/YYYY) 5. Service in Autonomous Body/State Government, if any particulars of service:

(a) Name of organization

(b) Post held

(c) Period of service From To Total period

(d) Whether the above service is to be counted for gratuity in the Government

Photograph of claimant(s)

Family Pension / Death Gratuity case on (Tick one box) Death of Government Servant Disappearance of Government servant

(e) Whether the Autonomous Organization has discharged its pensionary liability to the Central Government

(f) Amount of any pension/gratuity received for the previous civil service, if any

(g) Nature of any pension/gratuity received for the previous civil service, if any 6. Service qualifying for gratuity:

(a) Details of omission, imperfection or deficiencies in the service book which have been ignored]

(b) Periods of non-qualifying service: From To No. of Days Interruption in service condoned under Rules 27 & 28 Extraordinary leave not qualifying for gratuity Period of suspension treated as non-qualifying Boy service (2nd proviso to Rule 11) Periods of foreign service with United Nations bodies for which no pension contributions are payable/paid (Rule 29) Any other service not treated as qualifying service Total Period of non-qualifying service

(c) Additions to qualifying service: From To No. of Days Civil service (Rule19) Military service (Rule 20) Benefit of service in a State Government/ Autonomous Body Rule 13/Rule 14) Temporary status service (Rule 15) (half of the total period) Total Period of qualifying service

(d) Net qualifying service

(e) Qualifying service expressed in terms of completed six monthly periods (Period of three months & above is to be treated as completed six monthly period (Rule 45) 7. Emoluments

(a) Emoluments in terms of Rule 31

(b) Emoluments drawn during ten months preceding death/ disappearanceFrom (DD/MM/Y YYY) T o

Note: 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 may be mentioned in items

(a) and

(b) above (

Note 5 below Rule 31)

(c) Average emoluments (Rule 32)

(d) Emoluments or average emoluments (whichever is higher)

(e) Pay reckoned for family pension [same as

(d) ]

(f) Dearness Allowance on

(d) as admissible on the date of death/disappearance (g)Emoluments reckoned for gratuity/ gratuity (Rule 45) [

(d) +(f)] 8. Amount of gratuity Death gratuity (in case of deceased Government servant) Retirement gratuity (in case of missing Government servant)

Note: Difference between death gratuity and retirement gratuity will be payable in the case of a missing Government servant after the death is conclusively established or on expiry of seven years from the date of disappearance.

1. Name 2. Designation 3. Date of birth 4. Level of pay in the pay matrix 5. Basic pay 6 Date of entry in the Government service (DD/MM/YYYY) 7.Date of Death/ Disappearance (DD/MM/YYYY) 8. Length of qualifying service reckoned for pension/gratuity(as indicated in PPO) 9. Emoluments drawn during the last ten months 10. Emoluments or average emoluments, whichever is higher 11. Dearness Allowance on item (10) on the date of death/disappearance 12. Emoluments for gratuity [(10)+(11)] 13. Gratuity admissible (In case of missing Government servant): calculation to be shown as follows :- Emoluments for gratuity/4 x Qualifying Service (In completed six monthly periods, not exceeding 66.) 14. Death Gratuity admissible (In case of deceased Government servant): 15. Pay for family pension (as indicated in Pension Payment Order) 16. Family pension admissible (calculation to be shown as follows) :-

(a) Ordinary family pension : Pay x 30% subject to prescribed minimum and maximum

(b) Enhanced family pension: Pay /2 [Subject to prescribed minimum and maximum] 17. Amount of Fixed Medical Allowance, if admissible

Name Date of birth (DD/MM/YYYY) Relationship with the deceased Government servant/pensioner Postal Address

Signature of the Head of Office Application to be submitted to Pension Disbursing Authority by spouse/co-authorised family member for commencement of family pension on death of a pensioner or family pensioner

1 .

(i) Name of the Government servant/pensioner in respect of whom family pension is being claimed

(ii) Name of pensioner/family pensioner on whose death family pension is claimed

(iii) Date of death of pensioner/ family pensioner

(iv) PPO No. of pensioner/ family pensioner 2 Name and other details of claimant

1. Two specimen signatures of claimant (to be furnished in a separate sheet) (Two slips each bearing the left hand thumb and finger impressions may be furnished by a person who is not literate to sign his name. If such an on account of physical disability is unable to give left hand thumb and finger impressions he/she may give thumb and finger impressions of the right hand. Where a Government servant has lost both the hands, he/she may give toe impressions..) 2. Two copies of passport size photographs of the claimant 3. Undertaking for refunding any excess payment made by the pension disbursing Bank 4. Specimen signature or left hand thumb and finger impressions of guardian, in the case of the guardian who is not literate enough to sign his or her name 5. Two self -attested copies of passport size photograph of the guardian/nominee 6. Descriptive roll of the guardian/nominee, wherever applicable, showing the particulars of height and identification marks, self- attested. 7. Copy of PPO of pensioner/ previous family pensioner (To be provided, if available) 8. Proof of permanent address of the guardian. 9. Copy of death certificate of the deceased pensioner/previous family pensioner

1. Details of pensioner:

Name Office/Dept./Ministry Nationality Date of retirement Date of death (DD/MM/YYYY) PPO no.

1. Amount of monthly pension (including ad hoc increase, if any)/service gratuity sanctioned to the deceased pensioner 2. Amount of retirement gratuity received by the deceased pensioner 3. The amount of pension (including ad-hoc increase, if any)/service gratuity drawn by the deceased till the date of death 4. If the deceased had commuted a portion of pension before his death, the commuted value of the pension 5. Total of items 2, 3 and 4 6. Amount of death gratuity equal to 12 times of the emoluments 7. The amount of residuary gratuity payable, i.e., the difference between the amount shown against items 5 and 6

Note:- 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 deathcum-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.

*Providing Aadhaar No. is voluntary. However, if it is provided, consent to link it to bank account and also for authentication of identity from UIDAI for pension related purpose only, is presumed.

I, .................. , who have worked in (Name of Organization) on the post of ............................... , for the period from ..................... to.................................. , do hereby solemnly declare that, save with prior approval of the Competent Authority, I shall not publish in any manner, while in service or after my retirement, any information or material or knowledge which is related to the domain of the organisation and obtained by virtue of my working in the said Organization. This declaration is notwithstanding my responsibilities and liability, in terms of the relevant conduct rules, pension rules, laws dealing with offences relating to official secrets or national security and Intelligent Organisations (Restriction of Rights) Act, 1985 (58 of 1985), as the case may be. I further agree that in the event of any failure of the above undertaking by me, the decision of the Government as to whether it was likely to prejudicially affect the aspects stated above shall be binding on me.