Rule 4 — CCS

Name of the Government servant Designation Nationality

S.N. Name Date of birth (DD/MM/YYYY) Aadhaar no.* (voluntary) Relationship with Govt. servant Marital status Remarks Dated signature of Head of Office (1) (2) (3) (4) (5) (6) (7) 1. 2. 3. 4. 5. 6. 7. 8.

E-mail: (Optional) Place: Mobile: Date (Signature)

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

*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.

Details of family members:

4. Details of member of the family of Government servant who has been authorised under Rule 57(3) to submit this Form on behalf of the retiring/retired Government servant:

Name Relationship with the Government servant Aadhaar No.*(voluntary) Nationality 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 Reasons why Government servant is not able to submit this form

4. Details of bank:

the Bank Branch A/c No. IFS Code

Place: Date: DD-MM-YYYY a. b Death certificate Guardianship Certificate/ Indemnity Bond (Format 7) and Date of Birth Certificate in case the claimant is a minor. c d e Guardianship Certificate/ nomination and Medical Certificate in case the claimant is mentally disabled. Copy of the report lodged with the police. (in the case of missing Government servant only) Copy of the report from the police that the Government servant could not be traced so far despite all efforts made (in the case of missing Government servant only) f Indemnity Bond in Format 8 (in the case of missing Government servant only)

*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.

4. Postal address:

Flat/House No./Bldg. Name Street/Locality Village & Post Office/Block City & District State Pin Code Telephone /Mobile No. E-mail ID

A/c No. IFS Code

4. Details of Bank account to which family pension is to be credited

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

4. Details of Bank Account:

A/c No. and Branch IFS code

(Signature of the claimant/guardian)

4. He/she is informed that an inquiry will be held only in respect of those articles of charge as are not admitted. He/she should, therefore, specifically admit or deny each article of charge.