FINAL PENSION FORMS OF -2016

1 O.C.S.(Pen) Form - C

2 O.C.S.(Pen) Form - D

3 O.C.S.(Pen) Form - E

4 O.C.S.(Pen) Form - F

5 O.C.S.(Pen) Form - G

6 O.C.S.(Pen) Form

7 O.C.S.(Pen) Form

8 O.C.S.(Pen) Form

9 L.P.C

10. Declaration under Article 911,351(L),920 of CSR.

1 1. Specimen signature.

12. Left hand Thumb and Fingers impression.

13. Descriptive Roll

14. Passport size photograph.

15. Original Service Book Govt.servant.

16. N.D.C

L7. C.P.F cotribution

18. Leave statement

19. Undertaking

20. History of Service

21. Form-5A.

22. Loane/ Non-Loanee Certificate as per Finance Department letter

No-49300 I F,dtd.L2. 12. L997 .

23. Spl.H.B.A (HUDCO) clearance certificate.

24. AR/IR clearance certificate.

 O.C.$ {P[N$l0N] Fnrm-f;
{See H*}e-53 of *C$ {Fe**i*n}*u}*s, 39$?}
{See ftu!e-& sf fif$ {Conrmut*ti*n nf P*nsi*rr} Ruie*-t#$2

rSR pAyMrNT ilF Afift[Afis OF (*MMUTATI&IT VALUE I

NfrMilUATIOT\J
ffiTATH-CUM.RTTIRIMEITT SRATI.,IITY Aru* LIFT TIMH ARRTA*S #T PHNSION.

*n th* *v*nt nf my death, l, herehy ncnrinate the pers*n/persons

menti*ned below, who isfare members of my family/not * pa''t cf my {amily and confsr
on hirnlher/thsm th* right tp rereive the arrears arising out sf r*rnmutatisn value $f
pensiun and gratuity sanctirnud hut remaining unpaid, *nd also, life timr arrears *f
pensi*r* ar *ther *rrs*r$ payable to meo the paym*nt et which hav*r bq*n a*xtit*rised by

th* $tate Ssvernment h*t remain unpaid arcl conf*r *n hirnfher/thenr the right tCI
receive the arrears to the extent sprcified beiow against each.

ffriginai nominee{s} Alternate ncmimee{s}

Narnet a*d a*lclr*ss of fleiaticrrt- a{:ls ;v* a tt'i e. ;.r{iil r'trcl. [:ercerrtage
rrr:r:l ri**1nt:lrr.t ine es"
i sitip with fiirth *f of rhare of r+?,rti{}rrrhip *n# elat* of lhare nf
fi rf*fi r$. *I L:irth *{ thr: peruarr
tht 6ovt" the alrrsars.
5*rvant. Nomin*e $r pLarsonS, if xny, tt
i*teilr*rr r/Vyyl- whor"r th* righ*
ct:tnfr,:rr*cl a$ th*
trui{u ili*r}. lhft ii l:lats
ii: thr: t:vr:*t +f th*
nr:rfr']itr*l:
pred*ceasin; th*
(:ir:Vt.
$en,eci +r lh,;
nfrr?rir*tr rlyirig af iel
thr d*ath *f tlrr
#fvt s{-*tv;.lrtl i}t;t
!:ufc:rrr *,r+tiuiit$l
pfiyrticilt. *! rh*rr,: *f
i ilrrfi&fs

1 2 3 4 * 7

ffpfe- 3.Any Retiri*g fioy*rnrn*nf Siry*nr il*sir*u.x *f *ssigning tliff*r**t n*min**x fpr
rliff*r*nl typ* *f r!*ims m*y fit! in **p*r*t* {isrnts *f n*xri*tstirsn **r! suismit it
lc g:e*sirn s*nr:ti*ninE tsuth*rity/tiw* r;! Oilit;:-

fl+ntd
 Z" All c*l*mns slr*i"r/d b* lilled tn so {15 l.} i'ourr th* wh*lt r:*:GUr:l *! th* orra#rs
vtith r$er*rlcr ro th* pr:rcent*ySr:.

"*.iftis nrsmin*tiot; st"rpersrd*:; prtviisus *u,*tin*?i** i! r:ny fitr*is,h*d Sy rn*"

d"Ihe {iover!'?rfi(rti$fry#nf sh*il dtttx,tijn*> **r*-r.s fi:* h,r*nksfi#rr fusi**r", ffu* l*sf
trilfry l$ s:rr:v*nt llte: ifis*rtt*fi '*t ,:ny ri*fiit: *i'!€r !t* ht;,r :;ir:trfitrl

5, -$triks aut whirh is n*r *ppli':alsl*

tlated this.."..." ",."..day of nlanth -.. * "

*. * ". ". *., Z*,

Tw* witnesses tc signature:

4-.

Signatur* *f t*l* #overnment Servant"

Signature of the Head of Sffire

Bcc*FtiflB the *or"ninati*n
 #.C.S {P[N5l#fit] F*rm-il
[$ee ffiule 5# {}5}}

(lnfnrnratiort cn Seta{trs *f Farxily}

1. Namr of the Gnv+rnment $*rvant:-

?. #esi6nation:-
3. *at* nf Sirth ns pt*- S*rvir-il l3c:r*l<^-
j[. t]nte c]f Appr"rintmernt :*
5" tretails of the members of my family*as nn
{ddlmm/yyyyi

SLN1 N*rne of the members *fi Date nf Eelationship fiemarks if any

s, farnily+ Sirth{oo/mm with the
fwwl Sou*rnmcnt
5#rvaftt

fr.
5.
{"
*" I
i

fi*rehy undertake tc kecp the ab*v* particulars ilp-to-date by notifuing

$

ts th* l'{*;rd CIf cffic* .:ny ;rdrlition fir *ltmrati**s i* th* fanrily.

$ignature of the S*vernment $ervant

FIs$s :-
*at*:-
* $*mily fsr this purpsse ffi**f1s i'arnily as d*fined in clau*e
{b} uf s*h,rul* {if}*f Rule 55 g}f
the $disha Civilservices {Pen:;ion} Rr.rler*, 1.$97,

o+ Wlfe and l-{r"rgband shall inclurle r*sperti'r*ly

J*tIi*lally sep;rr*te:d lvife ***{ hushand
 s. {.s. { PEf\i5rsr\, } FsRM-r

PART-I
{H*ference fiul*- 5S{2} *f #CS {F*nsitnl ftuk*, t$S?
{Application by the Retiring 6cuernment Se,rvsnt fsr sanction of
and rulc 5,6,J"1,1e,f,3,3"3,14.*nd 1.5 *f #e$ {CF} ffiul*s, 1$9?
Penslcn, Sratu and tsrnrmutted Va*ue of Fen ion)
3 Nxme $f thc Governrn€nt S*rvilnt {ln ilf nck
t"*ttersl

?_ #ather/Spouse Sl*ma flat*$r ;-

t"i r.isband/\#ife

{ #xte cf birth {by Christian Hra}

{ln wmrds as recorded *n th* $*rvke $oeik}
{. Sate of Solnlng in Sovernment $srvice

s S*te,*f Retirement

F*st last served and the name of the Office

7 Type *f frenrion applicabte {$upor-annuati*n I

lnval id Pension/{* rn pensatiom Penrionf F,cn*inn
V*luntary RetirementfPcnsi** tn
uru
Connpulsory ftetirement)
L Frgvious Pensian / Family Pe*sion recelved, if
*ny, {rom other scurce / Mllitary 1 Civil.
FI**se iildisat the d*tails PP# / $$PS #o.-
Ar$silnt of Pension & clate from whirh received
o Farmanent Addrcss:-

ls. &Sdress fcr Ccrrrspondence {urhere th*

S*ruioner intends tc reside afte r retirem*nt)
Phone ns.
Mtlbile no"
f; nrail iel

11. {A} Hetiring Gcvernment Servants chcice nf the ttla,rT e *ithr: Aarrt
Banks where the pensionary benefits are tei fue
rredit*d.
I d rrch

A/L itu..........
I
IFSC C*de........ ..,....".."..,, MlCfi
i
i
C*rit*..^ ^..... ^...""
i
l

(cntS-..
 I
{S}Sa*k Ac{ount Eetails Fiam* *f th* I3;lnk
{wh*n *psrated $ingle I J*i*tiy lsitfi the
$ps$$* by the F*nsiort*r].
llr*r"*ch,...""........

l\/c
t'lr"\

tullcii

Blili C**ie
13. furnranent Account Number {fAI*} it any
{tor Incom* Tax Purp*sei
13 P*r*wnta6* {%} of Fensicn s**ght t* be
rsmmuted. {Maxirnunr 40% mf Perrsi*:n}
1&. **tails gf the family {famityfar tl'ris purp*r* nreans 5p*uxe-
ta*'riiy a* definad in claute {b}{;}{iii} *f s*b-ratrs {17} of $tuie Iln ll
5$ ot the $rissa Civil Servir:rs lFrnsinnJ |Iulc$, 1992"1
$prure/Srn/$on$ includin6 adopt*d s*ns/Un "married
$srdssrj
Hxughter/saughters inrluding adaptw* 0qpsftt€#F"rusl$ffi
Bwught*rs/Parant$lparcnt$'ir, -l;rw$ in c*re ${ Wr:merr
#sv*rnrrre*t fi nrployeej. $*Bl!4;*slisi*[ls:y".r
,i

|iSfS:"tfuif* {lrriJ hush,i,*d gir*li illirrr}t: r*tixr.i{tiririv :rrriilii'rilv

J
s#ps r"i}1*ti wrfe ilnd hliibi..rfi {:1.
t
p
A*y *ther lnfo;"nr.ltrcn. Ce*llflArSu.iilt)*Ldwljl" ta"se n f wCI rn gJi
Ci"p:s r:me"r ! $e $-a $$lQg-E/*&*

1^5. : Whether Nrlmination furnishrd in Forrn-3 , No*rineli*n ir.rrn: it tt; bn attaehes,

{Attac} fgry$"},
rs. tffhethcr applicatian for final urithdrawal of GPF
has tueen filed; {i} if y*s give th*. dat€ {ii} if no ilr!

the rsascns"
1?. Pers*n*! Nd*ntificatio* pruflf tft be attached {a} Fhotograpt'r {$lngls nrJrint} to b*
duty xttest*d by l{ead of Off}c*/Auth*rised ene lo*ed"
Sf*cer. {b} SercriBtive Rolls.
/Thurnb lrnpressicn.
18. tnf*rrmaticn nn Drarryal *f L*ng T*rm Advances
during the Service Period {6iv* details rsitlr TV
el*.1
{A} House Building Aduar*e
{B} Special lfsuss fi*"ti[r{lng Aduan**
{C} Motor (ar Advance
{D} Motor Cycle Advance
1A Flame of ?rcasury I $pecial ?reasury,f $ub
Treasury where the pensir:ner intends to draw
his/h*r first

$ignature of the Hetirf ng I R*t$red S*v*mnr.rant Sery*nt

llesignati*n befor*, ft etirem*mt.
 s,Ecr&s4r"r,p$ q r T }J E { -rl BJ$ $ cav EB t_r M E rur $

t. ,."...."""....... .., d* hereby givu rxy fre* a** full to*s*rrt th;*t if a*y +:v#r psyn"ler1t
r*arJe t* m* is rJetecred while in Eervicr *:r after fly rstir*{ne*t ir': r*sp*rt *f rny Seneral
Frr:vidrnt Funr{ Accrrtj,rt (:i1 r:rt irccr}urrt erf Gratuity, PerrEir:n and T*rtipcrr*ry increass on
P*r':siugr *tr., the same shall be rtecv*r*d frr:rm nty Terxporary lner*aso s*r Sension ur
Sratuity p*yxhle fo me *r to rily family *t any tinr*.

Full Signatur* sf thu Retirlng 6nvt"

$ervant with address.

PAMT.II

ACKruOWLESfiTMTT\,7

*ncsl$ed frslr*
$ri/Smt./Miss..
{**me *nd d*signati*n of thr retiring S*vermn*nRf S*rvant}
*pplicutir:n in Frrm-f; for sancti** of Fsnsinn I firatuity and Cnmm*t*ti*n V*lue of Psnsion
vsith Msdical Certificate / with*ut Medicai {*rti{icate *l<lng witlr rron:inati*n in Fomr-C

{*trike *ut wt"lich is not appli**hl*},

*
ft:* rxc*ry,rt *f the applitotisrr &y tlw tfe*d af #.ffir:e fI:*,4cfonowled6fffif;rlt s&*rjd he $efretre#fr*rn ffic
Form onrJ to be fuanded oyer t$ fire opplkrrnt *s n pr**! *f rer*ipt *! *ppiirrfiirnj.

Flac*:
#ate.,.""

$ignatur* of llead of OflicslAutlt*rised Authority

 o.c.s.tprNsr(}Nl roHM-r
{T* he Filted in by t}r* Head of #ffice for sanetirn rf Fensipnary henefits}
$ee Huls 5S{1}, Sr, S3{:"}, S3{AXI} & $4
pAtT-$
t Verificxtian slf informaticn details 6iven by th* r*tin*g Gfi$ernrnent VerlfiEr* the
: $ervants in CICS {Fension} Forrn-6 inf*rmati*n given
' i* *CS {Pensi*n}
I
'.,1rl11
i"- $\lxm* sf the Governrylsnt $crvant {ln 8L#CK L[fi{n$}
*" Tstal Feriod of Grssr $ervire
s. Trtal Period of l{on*Qualifui*g $ervice

ti) [xtra Srdinnry Luavc not Qu*lifying the Fensinn

tii) Period of Susp*nsi*R not treated ;rs qualifying s*rvice

{iii} Any otfrer period of service not qualifying for pensirn

il T$tal Period of Net Qualifying Service
{Srass Period of Service * Feriod *f ltlon-Qualifyine $efirire}
&" &rry *th*r 3eruiee Rendered t* be added tr thp Sualifuing $arviee
be ed the pSA with reference ta the $sruiee Scrk Hntry!
7 Tstsl perisd of Qualifuing $ervire far el*terrnination cf pensifir1.
$. $**le of Pay with 6rade Pag, if cny. at the tirne of Betirernent.
$" [mol*ments last drawn {Fay, Srade Pay *r Perr*na} fay, if a*y,
drawn as defined in ftule-?{e}{aXb} rif thr: OCS Ponsi*n &ules, L9$2
with Rule-48.
read
*s" Am*unt *f Pension F;lyabl* per m*rlth

t;. &mntrnt of 6ratuity pay;rble

{T*t*l fim*lurn*nt$ x No. trf l-la{f Year}y Qualifying S*.ru*c*} diuided hy
s+t tn maximsrrl ltmit"
ta" eomnnrted Value of Pensian {Subjected to maxiryrum iimit of 4*% of

:3. Reduced Pension Receivable after Cnrnmutation

3.4. A$$ilnt of Farnily Spnsi** Fuyable

iil
fiefor* attaiili 6$ years
{ii} After attairrirrg #5 y*ars "
*5. #utstanding frsvernmeilt duss for rerou*ry.
{x} *utst.lrrding Advances :-
i) l-{uuse 8*ildirrg Aelv;+r'rr:e lSp*cial l-{ouse Br":iltlirlfi
Aclvance witll lnterrrt j-
it) Motor far Advilnt"* with lnt*r{}.ttt-
llr ) Motor Cyete Advar:ce irith lnter*st
ib) OutstanrJing f*rs f*r ilccupati*n r:f Scv*rnm*r:t euart*r
ilverpaymrnt *f pay **d ;*lloln,ancrs incf *di*B Le*vtr
5,ela
{c} Any other *sssss** dxes pay;lhl* t* $sv*rnfl}x*t1t
{Ple*se indi*nte det*ils

Csritd,,,.
llt}. ! Ttrtel Sutstanding Sovernrnent S*ss fteeover*ble
!Y &rn*unt of Gratuity to he urithheld for r.rn-asx*sred dues
Net firatuity Payahle
{Excludi recsue om*$rlt and ttr* u*ithheld nm,lounti
1S" T$t{*t anrsunt ef Psnsi$n t# be f;srnffii"ited {$ilbjf;{t tr rutaxirnum uf
$f Fension!
4S,,4
?$. Age on next Birth nay.
':*vr
Tots| Amount of (ommutsd Valu€ *f Sension Fayable ln fieu *f
Ca*lmutntion {Calculation to be rnade as per f*rrnula}
51
t4, llet*il$ cf san*ion of Prauisional Pe*siun if any with dnte and
strt*urlt "

t7. Wh*ther applieation for fin*l withdrnwal af GFf has b*en sent to l;\,
A.s., sr, if the lett*r Nr" &datc {ii} if no give reas*nr. iii
:4. P{ac* *f pfryrr}f,,nt {Nam* nf Yr*asuryy'$pecial Trea*uryf
$uh ?reasury

$i$natur* csf the Haad *{ 0ffice

wlth 0fl$l6fllATlSFJ
 PAffiT-II

iFor r"*se hy Pens{rn $anctl*ning &r.*th*r[ty]

$ancti*rT is h*r*hy *cc*rdrrJ in favc:r-rr *f Shri/5mt ,1(l:r'v:4ri ......

{ i,,l* m* v"rith detitrgrra ti*n }

i* the $*pt.I*ffic* f*r p;*ynt**t *f prnsi*ru*ry hrruilfits as admissihle

xnrl*r rui*ls.
t.
Pefisisr: Commutatian Reduced Total Totatr S*mily F#*'!$,0n f{ame af
tlf Fension Pension *fter Crmmutati*n Retirer*ent tn th* evrnt ul the
Cr*lmutatigln ualue r:f Srat*ity de*th sf {he *[igible
P*n*it:lt Fenrinx*r. family
Sefrrre A.lter perrioner
6$ $$
rs

I t*f,*rryla{in* *rr sancti*n *f {:r*lnisirinri F*nsi*r'r/firatility and f<:rftmiltatisfi Vr},r}e *f Fnnsion

Provislonal P*nsionary ?rr:visionaI Fr*visionat Cc:mrnutati*n Pravisisnal
Bene{it* $anctisned Fensi*n Valu* af Fe,nsi*:n ftetirefftcnt Srat*
&m*uxt
$anctio* Ordar No.
Oate cf $anetla*
Sesignation cf the
5a nctio,n ing Auth.o ri ty,

Th* xnt*:rrrnt *f t,'utstartdirrii fioir#tn*iLttt rirrr;)s ;rrri tirg rirrllBr.irll t* ** rsi1i.:h*ki al *ugg*str,d i:r Part-1
*f this f*r*r shnll bt taker i*tr: ;rrcr"runt i:ef*rc ,ruth*ri;ing p**sir:n;lry benr*fits ta th* ftetirerj
6*ver*r'r:r'lrrt $Ervants bv tirc l\ccountant $ri,n*rai. Odisi'ur.

$ignature of the Pension Sanctioning

&uth ority and d*sign*tls r'*.
 rART-*1il

{$ee $ension fir*le-64} and I{ule.'34 *f fiC$ {fl*rnmutatlsn *$ Fensicn} ftutr**-19P?

.frflruHRAL, #nlsHe)
{A(dfiUnJT [NFACf;MTNT BY TH{ f}ntNflrAi- ,lft$Ut\XTAruT
i. f**trvrt: r:f fit:v*rtrr*trt 5{:iv;ll"ll
;*,
l. L!3SE i)t y{} nst0r'l
3. 6ri:ss 5e rvice Adrnltteci

4" A*J*itt*ri ne:n-qualifyin61 l*rvitr

$. rldnrltre** eyuaiif,Ting s*rvict:

$, ArJditi*n tr: qualifying s*rvi(.tr

?, &dmlttnd *ilol"trll of persion/ senric* (:rfltuily

8" Adrrtitted *rflsunt *f rstirern*rlt ${attlitY
$" Adrfiitts(l arn*u*t *f farnily 5:ensi*rt
i.} lle{ot* *tt*inin5,, {i5 vears
ii) Aftrlr iltt.ti{}irlg iiS yearl

1t],Affi *il fi t *f t:iltsta *di n$i G*verrt m*n { ci u*s re*t:ver*<J

fr*m
&m*ugrt withhcld from gratiiity pending ags*rsment
1.1.. *f
fi*ver*rrrerrt rlues.
L?,Cr:mruutsrl vaiue of F*nlion allE:w*d to s(lrr{lnd(}l'

13.N*t P*nsion Payai:[e nfter Cuntrnutati*n

14. $**t fl*mmuted Value of F*nsiorr Fayablt:

LS. ili*te *f **n":m*,nrsn'tent r.lf P*nsi*n.

-ltr. $ats *f C*inrr"l*ncerlrent *f Rr:d*cecl Pensinri after

Commutatiort:
1?, $'l*xci *f account to urhich pel*si*n*:ry h*tt*{its ,rr*
$ebit;lbie.

ACflOIJNTS OFFICHB
 0"f,"s. (pENsloN) ronM-G
{See ftule-$Z{*}
{Forwarding af Fensirn Fapers of the retiring 6overnment S*rvant t* th*
*ffice af the 4.6., CIdishn)
#SVHfrNIMENTOF il$'5HA

*Departm*nt

Tu

The Accountxnt Genera! {A&[], Sdishm

Bhuha*eswar.

$ub:* Fcrwarding of Prnsion Papers.

5ir,
I am direrted to forward herewith the p*nsion p&prr$ of
$ril5mt./Xu ffiarl
andCIesignatisn--workinginthisD*partfi?erutlsffirefsr
ne{psssry autharization for drawl of pension/comrvruted value cf pensio*/fir*tuity as p*r
tht suggestion given in O.t"$- {Pension} Forrr-F and *utstanding Government du*s are to
b* recovered frorn the retir*m*nt firatuity alnd pending asse$$meilt *f any ather
sut$tfrndingi $overnment ducs Bfflsilnt a$ $ugge$teci may b* withheld ?ilt final dscisisn in
thi* regard.

The fsct cf authorization of penri*nary bcn*fits h*s t* be intirn*ted t* this

*ff}rc/S*pertrnent.

Yours faitF*fuf ly,

Slgnature of the Fensinn $atrctioning

Authority with Sesignatian

S*t*ils of Inclosures :-

3.. SCS{Fension} Farrn-[.

?. 0C5(FensionI Form-F"
3. Nomination Farm in OC$ {Fension} Form C.

4" $pecirnen Signature. F*rsonal ldentification Mark &three c*plml of Fassport Size
J*int /slngle Photcgraph *f the r*tiring Govsrnm$nt Se ruant duly attest*d by
Pension Sanrtioning Authurity 1 Head af fff{ice "
5" ffrigin*l $ervice Bo*k"
$" Sriginal mselical Certifieate {in cms* *f i*va*i*l pcnsi*n}.
Memo Na. $t

(rpy forur*rded to Srilsmt./Kumari

At-- , P'S fii Fin-
for information and ne{essfrry actinn"

$ignature sf th* Fensisn $anetioning

Authority with **signation

Memo l{m"_._ #t.

C*py forwarded to the llead *rf Sffire far infarn*aticn and ns*es$ary actisn
with reference ta his nffice letter Ns. S*t*d

$ign*t*re of the Pe*s}*n $anctlcning

&uthority with Sesignation.