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ADDITION

MODIFICATION
DELETION
RECOVERY

Pension Modification / Addition Format


(* Mark fields are mandatory)

BANK OF INDIA
Branch ____________________

Date: _____/____/______

1. Type of Pension *

:___________________ ___ (State/Defence/Central Civil/Telecom/Railway)

2. Name of the Pensioner *

: __________________________________________

3. PPO Number *

:_____________________________( 12 digit PPO no required for Central Civil)

4. TS No /PS No

:__________________

5. Retiring Office/Dept

:______________________________

6. Designation/Rank & Group

:______________________________( Mandatory in case of Defence Pension)

7. SB ACCOUNT NO *

:_______________________________

8. Date of Birth *

:______/______/_______

9. Date of Retirement

:_____/______/_______

10. Pension Start Date*

: _____/______/_______

24. Pension Current Month : _______ Year _____


Basic:

11. Pension Start at Branch*

: _____/______/_______

DA :
Medical Allowance:

12. BASIC PAY*

Rs:_______________

13. Amount of Commutation

Rs:_______________

14. MONTHLY COMMUTATION

Rs:_______________

15. Date of Commutation

Other allowance any:


GROSS PENSION (A)
Commutation (B)
NET PENSION (A-B)

Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.

: _____/______/_______

16. Commutation Restoration Date : _____/______/_______ (15 years from the date of Commutation)
17. MEDICAL ALLOWANCE*
18. Date of Death

Rs: ____________________

18. OTHER ALLOWANCE Rs.____________________

:_____/______/______ ( In case of Family Pension)

19. CAPITALIZED VALUE

Rs:_____________________ ( on Retirement)

21. RETIREMENT GRATUITY

Rs:_____________________ ( on Retirement)

20. DCRG DIFF Rs.________________

22. Please pay Pension from month _________to _________ total Rs. ____________________
23. Remarks___________________________________________________________________________________________
________________________________________________________________
Note*: Medical Allowance of Rs. 300/- admissible for all state Govt. Pensioner/ Family Pensioner as per 6th
Pay commission w.e.f. 01.09.2008 . For Defence, Railway & Central Civil M.A. admissible only when it is
mentioned in PPO or in declaration basis that pensioner is not availing any Health/Medical Scheme .

Seal & Signature


(Manager)
Seal
& Signature
Manager/Sr. Manager/CM/AGM

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