To, All ACs-RDsIIC- (NT A) DlRECTORs/JD IIC All SMCs/SSMCslMSs of HOSPITALs/D(M)D/D(M)NOIDAlJD(E-V) HQRS.

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1 PANCHDEEP BHA WAN, C.I.G.ROAD, NEW DELHI No.A-40112/Misc/2011-A/Cs.IV Date: ~ ~ - r - 2P 1.3 All ACs-RDsIIC- (NT A) DlRECTORs/JD IIC All SMCs/SSMCslMSs of HOSPITALs/D(M)D/D(M)NOIDAlJD(E-V) HQRS. Sub: Regarding Format of Pension Payment Order, Gratuity Payment Order and Commutation Payment Order. The revised Format of Pension Payment Order, Gratuity Payment Order and Commutation Payment Order duly approved by Additional Commissioner (Fin.) is circulated for the guidance of all Head of Office is concerned. Hindi Version will follow. Yours faithfully, ~'TtG (R. S. Chauhan) Joint Director (Fin.) Copy to:- 1. All Joint Director (F)/ Deputy Director (F)/Dy. Director (F) A/Cs.1II Hqrs. Office for necessary action. / Website Content Manager with request to upload the said letter in website of ESI Corporation. ~ $I 1JQ~-"-""'" ~ ~ ft\~-:.. gamont.. ~""s \",a, IV \ Website C '" S?. :. 51 ~ /Oigf" No... \ '2... ~Fix\ ) 'L.7..!..0..3[... :.) \~.,i(~/ Date..,. (R. S. Chauhan) Joint Director (Fin.)

2 REGISTERED EMPLOYEES' STATE INSURANCE CORPORATION PANCHDEEP BHAWAN, C.I.G.ROAD, NEW DELHI No. Date: E.S.I. Corporation, Sub:- Pension Payment Order in respect of Sh.lSmt. The Pension Payment Order (Pensioner's and Disburser's portion) 111 respect of Sh.lSmt. is forwarded herewith for arranging payment. The pension or provisional pension paid earlier, ifso, may be adjusted before making the payment. 2. The Dearness Relief on Rs. /- w.e.f. is admissible in accordance with the instructions issued by the Central Govt. from time to time. 3. The instructions contained in Chapter V of ESIC Pension Manual may please be strictly adhered to while making the payment of pension to the pensioner. 4. The pension has to commence from (As per PPO enclosed). 5. He/She has desired to draw his/her pension through your office. It may be paid accordingly as per instructions on the subject. 6. The photographs specimen signatures of pensioner and service book and service cards are returned herewith, which may kindly be acknowledged. Encl: As above Yours faithfully, JT.DIRECTOR (FIN.) I. Sh.lSmt. He/she should appear before concerned Dy. Director (F)/Branch Manager for his/her pension. 2. The Region Director/ Joint Director/ Incharge/ Director/ Medical Superintendent/ ESIC, RO/SRO/ESI Model Hospital,, -A ~1~t\1 -<-01 lj~ ' " c;-qmsr: «1'\ IC" '-< '/>. ~1-e,amef1t...,.,... " SIt. t'c.rw,..c, I ", '" v leo, s- e,.j ' I.',. -,.. ~t!':di., '0;') <)...,....'.' n J \ ~.;..."/ ~.~,~.'. 7-7 (! /.. for JT. DIRECTOR (FIN.)

3 Passport size Photograph Under Rs. /- w.e.f. and Under Rs. 1- w.e.f. the date of payment of CVP Pay Band of Post held PENSION PAYMENT ORDER PENSIONER I DISBURSER PORTION Head of Account Expenditure on Employee Benefit To which pension Provisions for Employees Benefit Is to be debited Pension payment Name, Designation, Class of Pen. & Personal Height Residential Address Amount of Monthly Date of Birth & Age the date of identification Basic Pension/ Family commencement mark, if any Pension (He/She has commuted Rs. 1- out of the basic pension of Rs. 1-) EMPLOYEES' STATE INSURANCE CORPORATION PANCH DEEP BHAWAN, C.I.G.ROAD, NEW DELHI No. Date: Until further notice and on the expiration of every month be pleased to pay in respect of Sh.lSmt. the sum of Rs. w.e.f. and Rs..I- w.e.f. the date of payment of CVP as above being the amount of Pension upon the production of the Pensioner's portion of this order and taking from the claimant a receipt for the amount according to usual form. The payment should commence from In the event of the death of Sh./Smt. Family Pension of Rs. ---:I- (Rupees ) is payable upto OR for a period of 7 years from the date following the date of death of pensioner, whichever is earlier, and thereafter Rs. I-(Rupees ) may be paid to Sh./Smt. (HusbandlWife) (D.O.B. - ) till the date of his/her remarriage or death whichever is earlier (on receipt of death Certificate and Form-14 application from widow/widower/children). Additional quantum of 20%, 30%, 40%, 50%, and 100% of basic pension is also payable when the pensioner Note: - 1) 2) attains the age of 80 years, 85 years, 90 years, 95 years and 100 years respectively. Dearness Relief on basic pension is payable from time to time as admissible under rules. No Dearness Relief on pension is payable during the period of employmenure-employment of pensioner. 3) If the pensioner is in occupation of Staff Quarter, the license feeldamage Charges of Staff Quarters may be recovered from pension and D.R. in accordance with undertaking in form-5. 4) Before operating this P.P.O earlier P.P.O's (both halves), if any, may be returned to this office. Dy. Director (F), E.S.1. Corporation, JT. DIRECTOR (FINANCE)

4 PANCHDEEP BHA WAN, C.I.G ROAD, NEW DELHI Date of Retirement- Not payable before- No. E.S.1. Corporation, GRATUITY PAYMENT ORDER Under Rs.. Date: Subject to obtaining the Vigilance Clearance as on the date of cessation of service of the employee, and adjustment of the Corporation's dues etc. as per details given in para-6 below, please arrange to pay the Retirement/Death Gratuity amounting to Rs. /- (Rupees only) to Sh.!Smt. ---,----: 2. The particulars of the recipient of gratuity are given below and details of height, identification marks, specimen signature of left/riahte ngi t hand th um b impression an dhpi oto etc. m tia ie nnexure enc Iose d to thpe ens IOn P ayment Odr er. Name, Designation, Personal Height Residential Address Date of Birth & Age identification mark, if any 3. 1he gratuity IS debitable to the Head Expenditure on Employee Benefit I ProVISIOns for Employees Benefit I Gratuity Payment. 4. The acquittance/bill with requisite revenue stamp, should be taken by the Disbursing Officer from the gratuitant. 5. The gratuitant is being informed of the issue of this order. 6. Amount of Gratuity Rs. Details of dues adjusted Less already paid Rs. Outstanding dues adjusted Rs. Amount withheld for want of N.D.C/L.P.C and Service* Verification Certificate Rs. Net Amount payable Rs. Subject to adjustment of Corporation's Dues (Unassessed) up to date of Retirement), if any and Provisional Gratuity already Paid. (Rupees only) 7. The date of payment of gratuity and amount disbursed (with details of recoveries from net amount), may be intimated to this office immediately after payment, indicating the letter No. & date of this order. Yours faithfully, JT. DIRECTOR (FIN) 1. Sh.lSmt. He/She should Contact/appear before the above Disbursing Officer for his/her payment. 2. The for information and necessary action. (i) The orders for releasing the withheld amount of Gratuity may be issued by the Regional Officer/Head Office within one month of the cessation of Service of the employee, but invariably before the expiry of six months from the date of Retirement/Death of the employee, in the performa circulated vide Hqrs. letter No.A-40 (I 0)4/89.AlCs.lV dated / along with the Last Pay Certificate, No Dues Certificate and Service Verification Certificate (for onward transmission to Hqrs. Office to the disbursing officer i.e. Dy. Director(Finance) in the concerned Region. Copies of the release order may be endorsed to (ii) the gratuitant i.e. to whom the withheld amount of gratuity is to be paid for JT. DIRECTOR (FIN.)

5 PANCHDEEP BHA WAN, C.I.G.ROAD, NEW DELHI Date of Retirement Not payable before- No Under Rs. Date: COMMUTATION PAYMNET ORDER E.S.I. Corporation, Subject to obtaining Vigilance Clearance as on the date of cessation of service of the employee, I request you to make arrangement for payment of commuted value of pension amounting to Rs.. --'I-(Rupees only) to Sh.lSmt. holder of the pension payment order of even no. dated as soon as possible on obtaining the proper receipt. A separate bill should be prepared for the payment of commuted value quoting the number and date of this letter as an authority. The fact of such payment having been made and the amount of residuary pension of Rs.. I-p.m. should then be recorded in both the halves of the original P.P.O and future payment of pension be regulated accordingly. The P.P.O should not be returned to this office. I. Amount of Basic Pension before commutation Rs. 2. Amount of Pension commuted Rs. 3. Amount of Reduced Pension payable after commutation Rs. NOTE: (i) Date of payment of commuted value of pension of Rs. to this office forthwith. (ii) Reduced monthly pension after Commutation credited into the pensioner's account by the Bank. The receipt of this letter may please be acknowledged. I-may please be intimated will take effect from the date of Commuted value is You rs faithfully, JT. DIRECTOR (FIN.) 1. Sh.lSmt. 2. The for JT.DIRECTOR (FIN.)