Subject: Commutation of pension without medical examination

Transcription

1 1 P age14 FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF PENSION WITHOUT MEDICAL EXAMINATION FORM 1-A (To be submitted in duplication within one year after retirement) (To be filled in by the applicant) To, The Director Indian Institute of Technology Kanpur Subject: Commutation of pension without medical examination Sir, I desire to commute a fraction of my pension as indicated below in accordance with the provisions of paragraph 20 of Schedule F of statue 16B of the Institute. The necessary particulars are furnished below: 1. NAME (IN BLOCK LETTERS).. 2. Fathers Name (Also Husband s name in the case of a female employee.. 3. Designation at the time of retirement.. 4. Name of Office/Department in which employed last.. 5. Date of birth (by Christian era) as accepted for retirement.. 6. Date of retirement.. 7. Class of pension admissible/sanctioned.. 8. Amount of such pension if already sanctioned (In case final amount of pension has not been Authorized indicate the amount of provisional Pension sanctioned Fraction of monthly pension proposed to be Commuted subject to maximum of 40% thereof and not the amount in Rupees.. Pg.1

2 2 P age If pension proposed to be commuted has already been sanctioned, give Office Order No. and date by which it was sanctioned 11. Opted for fixed Medical Allowance/OPD Medical Facility as per rules. Dated: Signature.. Postal Address:.. ACKNOWLEDGEMENT Received from Dr./Shri... Ex.. Application in part (A) of the Form for the commutation of fraction of pension without medical examination. Date:. SIGNATURE RECEIPT ASSISTANT Pg.2

3 3 P age14 Dated: To The Director IIT Kanpur Sir, Subject: Request for final payment of C.P.F./G.P.F. I am going to retire on..therefore, kindly arrange to make final payment of my C.P.F./G.P.F. on the date of my retirement. Thanking You Yours Faithfully Signature Name.. Designation. P.F.No.. Department.

4 4 P age14 FORM IX NOMINATION FOR FAMILY PENSION I, hereby nominate the persons mentioned below, who are members of my family, to receive in order shown below the pension which may be granted by the Institute in the event of my death after completion of 5 years of qualifying service. Name & address of the member Relationship with the employee Age Whether married or unmarried The nomination supersedes the nomination made by me earlier on N/A which stands cancelled. N.B. The member of staff should draw lines across blank space below the last entry to prevent the insertion of any name after he has signed Dated this.day of..(month) of 20.. Signature of Subscriber Two witness to the Signature: Name(in full). 1. Signature Designation.. Name (in full). Personal File No.. Designation & Deptt 2. Signature. Date of Permanent/Regular apptt.. Name (in full). Deptt. Designation & Deptt Signature of DOFA

5 5 P age14 APPLICATION FORM FOR GRANT OF PENSION/DEATH-CUM-RETIREMENT GRATUITY, ON RETIREMENT FORM 3,5 AND 7 (To be submitted in duplicate) PART-1 1. Full name of the employee in BLOCK LETTERS 2. Personal File No. 3. Three joint passport size photographs with wife/member nominated to receive Family Pension/Death-cum-Gratuity Retirement Gratuity duly attested by a responsible Officer of the Institute NOTE: One Copy of the photograph Should be affixed here and the Other two should be enclosed with the application here. 4. (a) Height (b) Personal Identification marks 5. (a) Date of Birth (b) Date of commencement of Service in the Institute (c Date of Retirement/Death 6. Name of the present or last appointment held 7. Deptt./Section to which the applicant belonged at the time of retirement/death. 8. PRESENT ADDRESS ADDRESS AFTER RETIREMENT 9. Manner in which the payment of pension is desired and if at State Bank of India, IIT Branch, please state your SBI Account No. 1

6 6 P age Details of the Family in Form-3 appended below: Serial Name of the Date of Relationship Initials Remarks Number Members of Birth with the of the Head Family* employee of the Office (i) (ii) (iii) (iv) 11. Amount and nature of Pension, if any Received for previous employment. Signature/Thumb Impression of the Employee/applicant 12. Thumb and finger impressions of left hand in case of male and of right hand in case of female applicant, but only if he/she cannot sign his/her name. (Thumb) (Fore Finger) (Middle Finger) (Ring Finger) (Little Finger) 13. Declaration by the employee/applicant I hereby accept that if any excess payment on account of pension/gratuity including Death-cum-Retirement Gratuity is made to me, the over-payment so made may be subsequently adjusted from the pension/gratuity which may be payable to me. Dated:... (Signature/Thumb impression of the employee/ applicant) NOTE: 1. The term family for purpose of family pension means and includes the following: (a) Wife in case of male and husband in case of female employee/applicant (b) Son(s)/Unmarried daughter(s) who have not attained the age of 25 years including minor son(s)/minor daughter(s) adopted legally before retirement. 2. The term family for purpose of Gratuity means and includes the following: (a) As in 1(a) above (b) Son(s) including step/adopted son(s) Unmarried daughter(s) including step/adopted daughter(s) (d) Widowed daughter(s) including step/adopted daughter(s) (e) Father and/or mother (f) Brother(s) below the age of 18 years including step brothers and unmarried and/or widowed sister(s) including step sisters. (g) Married daughter(s) 2

7 7 P age14 INDIAN INSTITUTE OF TECHNOLOGY KANPUR (PENSION UNIT) Application Form for Grant of Pension/Death-Cum-Retirement Gratuity on Retirement (TO BE SUBMITTED IN DUPLICATE) PART-A (To be filled by the employee-applicant) 1. (a) Full name of the employee In Block Letters (b) Father s/husband s name 2. Personal File No. of the applicant Opted for: OPD Medical Facility OR Fixed Medical Allowance Affix a passport size Photograph duly attested by a responsible Officer of the Institute APPLICANT S PHOTOGRAPH 3. Address of the applicant after retirement For the purpose of correspondence 4. Applicant s date of birth as per Institute s records 5. Date of commencement of service in the Institute by the applicant 6. Date of retirement/voluntary Retirement/ Voluntary Retirement under SVRS/ Termination of applicant s service 7. Name of the present post held 8. Deptt./Section to which the applicant Belonged at the time of retirement/ Termination of service 1

8 8 P age14 9. Name of the retirement benefits scheme Opted for by the applicant 10. Class of pension admissible 11. Whether nomination made for:- (a) Family pension In case of yes, also Give the name of nominee YES/NO (b) Death-cum-Retirement Gratuity In case of yes, also Give the name of nominee YES/NO 12. Amount and nature of pension, If any, received for previous Employment. 13. Thumb and finger impressions of left hand in case of male and, of right hand in case of female applicant, but only if the applicant cannot sign. (Thumb) (Forefinger) (Middle Finger) (Ring Finger) (Little Finger) 14. Joint passport size photograph with wife/ Husband or member nominated to receive Family pension/d.c.r. Gratuity duly Attested by a responsible officer of the Institute. Space for affixing the Photograph (As required at Sl.14 in the margin) 2

9 9 P age Details of applicant s family as on the date of application. (Please see note 1 and 2 below) Sl. No 1 Name of the family member of employee applicant His/her relationship with the employee applicant Age/date of birth in case of minor(s) Manner in which the payment of Pension is desired. If at SBI, IIT Branch, please state your Account No. 17. Declaration by the employee applicant Signature/Thumb Impression of the Employee-applicant I hereby accept that if any excess payment on account of Pension/Gratuity including Death-cum-Retirement Gratuity is made to me, the over payment so made may subsequently be adjusted from the pension/gratuity which may be due/payable to me. Date...Signature/Thumb Impression of the Employee-applicant NOTE-1 The term Family for purpose of family pension means and included the following;- (a) Wife, if the applicant is a male employee (b) Husband, if the applicant is a female employee Minor son(s) including son(s) adopted legally before retirement (d) Unmarried minor daughter(s), daughter(s) adopted legally before retirement. 2. The term Family for purposes of Gratuity means and includes the following;- (a) Wife/husband, as the case may be, of the applicant-employee 3

10 10 P age14 (b) Son (s) (c) Unmarried daughter(s) (d) Widowed daughter(s) including step and adopted son(s) and Including step and adopted unmarried daughter(s). (e)father and/ or mother (f) Brother(s) below the age of 18 years and unmarried and/or widowed sister(s) (g) Married daughter(s), and (h) Children of a predeceased son. PART-B (To be filled by the Pension Unit) 1. Name of the employee 2. Personal File No. 3. Department/Section 4. Date of Birth 5. a) Date of entering in the Service of the Institute b) Date of entering in the service on daily wage/consolidated 6. Date of Retirement 7. Name of the retiral benefits scheme Opted for 8. Gross period of service Up to the date of retirement Year(s) Month(s) Day(s) 9. Period of non-qualifying service a) Interruptions b) Extra-ordinary leave not qualifying for pension c) Period of suspension not treated as qualifying for pension 4

11 11 P age Net period of qualifying service Year(s) Month(s) Day(s) Up to the date of retirement 11. Pay held during last 36 months:- Scale of Pay Amount of Period for which drawn Basic Pay From To a) b) c) d) _ 12. Last pay drawn:- a) Basic Pay b) Special Pay, if any c) Personal Pay, if any Dealing Assistant Superintendent Dy. Registrar (F&A) Date PART-C (To be completed by Pension Unit) Year(s) Month(s) Day(s) 1. Gross period of service From _ to 2. Period of Non-Qualifying service as mentioned in Part-B which has been deducted from the Gross Period 3. Net qualifying service which has been accepted for grant of superannuation/ Retiring/invalid/compensation pension 5

12 12 P age14 Calculation of average emoluments: a) of last 10 months Month Basic Pay Total_ b) The sum of average emoluments plus the amount of Dearness Pay admissible thereupon comes to:- Pension on 33 years of service /10= Rs Rs. Rs. Proportionate pension as per length of service Dearness Relief as admissible From time to time Rs. 6

13 13 P age14 8. Date from which superannuation/retiring Invalid/compensation pension is to Commence 9. The amount of Death-cum-Retirement Gratuity admissible (a) Last pay drawn (b) Dearness Pay Rs. Rs Total Rs. 10. Family Pension: (a) Last Pay drawn Rs. (b) Family of the pay Subject to minimum of Rs. and Maximum of Rs. Twice of normal family pension as Determined at (b) above (d) Half of last pay drawn (e) Amount of superannuation/ Retiring pension sanctioned To retire (f) Family Pension admissible Amount of (Lowest of and (d) or (e) above) Rs. Rs. Rs. Rs. Rs. 11. (a) The amount of family pension which Would be payable at the enhanced rate In the event of death of the pensioner After retirement for a period of 5 years From the date of death, or up to i.e. the date when the retiree would have attained the age of 65 years (had he survived) since it falls earlier to the date of expiry of the period of 7 years from the date of death. (b) The amount of family pension payable thereafter at the normal rate. Rs. Rs. 7

14 14 P age Name and relationship of the (a) Member of family of the deceased employee to whom the family pension would be payable (b) The period up to which the family pension would be admissible along with details of other terms and conditions subject to which it would be admissible. Dealing Assistant Superintendent Dy. Registrar (F&A) PART-D 1. The service details of Shri Given in Part- B of this form have been verified and found to be correct. 2. The calculation of pension of Rs_p.m. (Nature of pension) Payable w.e.f. plus R.I.P has been checked and found Correct. 3. Family pension at enhanced rate of Rs. up to and Ordinary rate of Rs. thereafter is correct. R.I.P. has also been Checked and found to be in order. 4. The amount of Death-cum-Retirement Gratuity worked out to be Rs. Has been correctly calculated. Internal Audit Officer Orders of the Pension Sanctioning Authority Sanction may kindly be accorded to the payment of pensionary benefits, as given in part- D to On his/her superannuation/retirement from service on.after Commutation of portion, of his/her original pension, the residual would be Rs. p.m. Registrar Dy. Registrar (F&A) APPROVED DIRECTOR 8