FORM-3

[See Rule -54 (12)]

Details of Family
1.

Name of the Government servant

:-

2.

Designation

:-

3.

Date of birth

:-

4.

Date of appointment

:-

5.
S.L.
No.

Details of the members of my family (*) as on :Name of the members of family

Date of Birth Relation ship Initials
of Remarks
with
the the Head of
officer
Office
2
3
4
5
6

1
1.

2.

3.
I hereby undertake to keep the above particulars up-to-date by notifying to the Head of Office
any addition or alteration.

Signature of Government servant

Place :Dated the

(*) Family for this purpose means family as defined in Clause (b) of sub -rule (14) of Rule 54 of the
CCS (Pension) Rules, 1972.
Note :- Wife and husband shall include respectively judicially separated wife and husband.

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FORM-5
[See Rules 59 (1) ( c ) and 61 (1) ]
Particulars to be obtained by the Head of Office from the retiring Government servant eight
months before the date of his retirement.
1.
2.

Name

:-

(a) Date of Birth

:-

(b) Date of retirement

:-

3. Two specimen signatures ( to be furnished

in a separate sheet ) duly attested by a
Gazetted Government servant.

:-

Enclosed.

4. Three copies of passport size joint

photograph with wife or husband ( To be
attested by the Head of Office).

:-

Enclosed.

5. Two slips showing the particulars of height

and personal identification marks duly
attested by a Gazetted Government Servant. :-

Enclosed.

6. Present address.

:-

7. Address after retirement.

:-

8. Name of the Treasury or the Branch of

:Public Sector Bank or the Pay and Accounts
Officer through which the pension is to be drawn.
9. Details of the family in Form 3.

:-

Enclosed.

10. Indicate whether family pension is

admissible from any other source- Military
or State Government and /or a Public Sector
Undertaking/Autonomous Body/Local Fund
under the Central or a State Government.
:-

Place :Dated the :-

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Signature :Designation :Ministry/Deptt./Office.

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FORM 1- A
FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF SUPERANNUATION PENSION
WITHOUT MEDICAL EXAMINATION WHEN APPLICANT DESIRES THAT THE PAYMENT OF THE
COMMUTED VALUE OF PENSION SHOULD BE AUTORISED THROUGH THE PENSION PAYMENT ORDER.
[See Rules 5(2), 12,13(3), 14(1) and (2),15(3)]
(To be submitted in duplicate at least three months before the date of retirement)
To:

The Superintendent,
__________________
______________________

(Here indicate the designation and full address of the Head of office)
Subject :- Commutation of pension without medical examination.
Sir,
I desire to commute a fraction of my pension in accordance with the provisions of the Central Civil Services
(Commutation of Pension) Rules,1981. The necessary particulars are furnished below:1

Name (in Block Letters)

Fathers name ( and also husbands name

in the case of female Government servant
Designation

3
4
5
6

7
8

Name of Office/Department/Ministry in
which employed
Date of Birth (by Christian era)
Date of retirement on superannuation or on
the expiry of extension in service granted
under F.R. 56 (d).
Fraction
of
superannuation
pension
proposed to be commuted.
Disbursing authority from which
pension is to be drawn after retirementa) Treasury/Sub-Treasury ( Name and
complete address of the Treasury/SubTreasury to be indicated)
b) i) Branch of the nominated
nationalized bank with complete
Postal address.
ii) Bank Account No. to which
monthly
pension is to be credited
each month
c) Account
Office
of
the
Ministry/Department/Office

Place :

Signature:

Date :

Present Postal Address:

Postal address after retirement :

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PART II
ACKNOWLEDGMENT
Received from ____________________________________________________ application in Part- I of Form I-A
for commutation of a fraction of pension without medical examination.

Place :

Signature

Date :

Head of office

Note :- If the application has been received by the Head of office before the date of retirement on superannuation,
this acknowledgement should be detached from the Form and handed over to the applicant. If the form has been
received by post, it has to be acknowledged on the same day and the acknowledgement sent under registered
cover to the applicant. In case it is received after the specified date, it should be accepted only if it has been put
into the post on or before that date subject to the production of evidence to that effect by the applicant.

PART III
Forwarded to the Accounts Officer
(here indicate the address and designation) O/o The Director of Accounts (Postal), ___________________
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
.________________/- and ;

iv)

the amount of residuary pension after commutation will be Rs. _____________/-

2.

The pension papers of the applicant completed in all respects were forwarded under this Office letter No.
____________________________________ dated _______________. It is requested that the payment of
commuted value of pension may be authorized through the Pension Payment Order which may be issued
one month before the retirement of the applicant.

3.

The receipt of Part- I of this Form has been acknowledged in Part-II which has been forwarded separately
to the applicant on ______________.

4.

The commuted value of pension is debitable to Head of Account 3201-PS-07-102.

Place :

Signature :

Date :

(Head of Office)

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1
2
3
4
5
6

8
9
10
11

FORM 7
Form for assessing Pension / Family Pension and Gratuity
[ To be sent in duplicate if payment is desired in a different circle of accounting unit ]
[See Rules 58, 60, 61 (1) and (3) and 65 (1)]
PART I
Name of the retiring Government employee
Fathers / Husbands name
Height
Marks of Identification
Date of Birth
Service to which belongs (indicate name of
organized service, if any, otherwise say,
General Central Service)
Particulars of post held at the time of
retirement (a) Name of the Office
(b) Post held
(c) Whether the appointment mentioned
above was under Government or outside the
Government on foreign service terms ?
Whether declared substantive in any post
under the Central Government ?
Date of beginning of service
Date of ending of service
Cause of ending of service a] Voluntary retirement on being declared
surplus ( Rule 29)
b] Permanent absorption in Public Sector
Undertaking/Autonomous Body ( Rule 37 -A )
c] Due to abolition of post ( Rule 59)
d] Superannuation ( Rule 35)
e] Invalidment on medical ground ( Rule 38)
f]Voluntary/premature retirement at the
initiative of the Government Servant
[ under Rules 48, 48-A & FR 56 (k)]
g] Premature retirement at the initiative of
the Government [ Rule 48 or FR 56 (j)]
h] Compulsory retirement ( Rule 40 )
i] Removal/dismissal from service
( Rules 24 and 41)
j] Death

12

13

14

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.
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
Particulars relating to 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?
(d) If answer to (c) above is in the
affirmative, whether the terminal benefits have
been refunded
(e) In case of Ex-Servicemen who are
eligible for family pension under the Armed
Forces Rules, whether opted to retain family
pension under the Armed Forces Rules or to
draw family pension under the Civil Rules

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--

---

-------

--

15

16

16-A

17

18

--

Particulars relating to service in autonomous

body, if any (a) Particulars of Service :
Name of Organization
Post held

Period
From
---

--(b)Whether the above service is to be

counted for pension ?
(c)Whether the Autonomous Organization
has discharged its pensionary liability to the
Central Government ?
Whether any departmental or judicial
proceedings are pending against the retiring
employees?
Has the retiring Govt. Servant worked in any
of the Organizations mentioned in sub-rule
(3A) of Rule 8 of the Central Civil Services
(Pension) Rules, 1972 and whether the
undertaking given by him in Form 26 has
been placed on record?
Qualifying services(a)Details of omission, imperfection or
deficiencies in the Service Book which have
been ignored [ under Rule 59 (1) (b) (ii) ]
(b) Period not counting as qualifying service (i) Boy service (2nd proviso to Rule 13)
(ii) Extraordinary Leave not counting as
qualifying service ( Rule 21 )
(iii) Periods of suspension not treated as
qualifying service ( Rule 23 )
(iv) Interruptions in service [Rule 27 (1) (b)
and Rule 28 (c) ]
v) Periods of foreign service with United
Nations bodies for which United Nations
pension has been availed
(vi) Any other period not treated as qualifying
service ( give details )
(c) Additions to qualifying service (i) Military Service (Rule 19)
(ii) War Service (Rule 20)
(iii) Weightage on voluntary retirement on
being declared surplus (Rule 29)
(iv) Weightage under Rule 30
(v) Benefit of service in an Autonomous Body
(Rule 37)
(vi) Weightage under Rule 48-B
(d) Net qualifying service
(e) Qualifying service expressed in terms of
completed six monthly periods (period of three
months and over is treated as
completed six monthly period)
Emoluments (a) Emoluments drawn during 10 months
preceding retirement From
To

--

--

--

--

----

---------

Rate of pay

Amount

Total

19
20

(b) If the officer was on foreign service

immediately preceding retirement, the notional
emoluments which he would have drawn
under Govt. but for being on foreign service.
Average emoluments reckoned for pension
(d)
Emoluments reckoned for retirement
gratuity /death gratuity
(e) Emoluments reckoned for family pension
Date on which the retiring employee submitted
his application for pension in Form 5
Complete and up-to-date details of the family
as given in Form 3

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To
--

--

Sl. No.
1.
2.
3.
21
22

23

24

25

26
27

28

29
30

Name of the Member

of the family

Date of Birth

Relation with the

Govt. servant

Whether nomination made for death gratuity /

retirement gratuity
The date on which action initiated to (a) Obtain the No demand certificate from the
Directorate of Estates as provided in Rule 57
(b) assess the service and emoluments
qualifying
for pension as provided in Rule
59 and
(c) assess the Government dues other than
the dues relating to the allotment of
Government accommodation as provided in
Rule 73 (1)
Details of Government dues recoverable out
of gratuity (a)
Licence
fee
for
Government
accommodation [ see sub rules (2), (3) and
(4)of Rule 72 ]
(b) Dues referred to in Rule 73

--

(a) Proposed pension / service gratuity

(b) Proposed dearness relief on pension
( as on the date of retirement )
(c) Date from which pension is to commence
Rate of Family Pension (a) Enhanced rate
(b) Period for which family pension will be
payable at enhanced rate
(c) Ordinary rate
(d) Date from which ordinary rate of family
pension will be payable
Amount of retirement gratuity / death gratuity
Commutation of pension (a) Whether simultaneously applied for
commutation of pension with the pension
application ( applicable only in the case of
those who retire on superannuation pension) ?
(b) The portion of pension commuted
(c) Commuted value of pension
(d) Amount of residuary pension after
deducting commuted portion.
(e) Date from which reduced pension is
payable
Name and address of Bank / Pension
Accounting Office from where pension is to be
drawn
Head of Account to which pension and gratuity
are debitable
Post-retirement address of the retiree

Signature of the Head of Office

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FORM-5 ( 3)
Specimen Signature of Shri. ___________________________________________ duly attested by a
Gazetted Government servant.

1]_____________________________
2]_____________________________
3]_____________________________

FORM 5 (4)
Passport size photograph of __________________________________
________________________________ ( To be attested by the Head of Office).

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with

his

wife

FORM-5(5)
Particulars of Height and personal identification marks of Shri. _______________________
__________________________________duly attested by a Gazetted Government servant.

1]

Height

2]

Personal marks for identification

FORM-5 (6 & 7)

Complete Postal Address of Shri. _________________________________________________

Present Postal Address :-

Postal address after retirement:

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Left hand thumb and finger impressions of Shri _____________________________

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