(A) CHECK LIST FOR PENSION PAPERS

Sr. No List of Documents to be supplied Documents demanded by

UHBVN
1 Application for pension By Retiree

2 Form of Assessment and sanction of By Controlling Authority

Pension/Family Pension & DCRG

3 Last Pay Certificate By Controlling Authority

4 NDC on Prescribed Performa By Controlling Authority

5 EPF/CPF Certificate By Controlling Authority

6 Three Copies of Joint Passport Size Photograph By Retiree

7 Three Slips Showing Marks of Identification By Retiree

Marks duly attested
8 Three Specimen Signatures of Husband and Wife By Retiree

9 Service Book duly completed including pay By Controlling Authority

verification by A.O/PF.
10 Service Statement in case of Gazetted Officer. By Controlling Authority
11 Form Pen-2 (Sr. No.11) Commutation Application By Retiree (Option)

12 Retirement Office Order By Controlling Authority

13 Orders for Release /Sanction of Full Pensionary By Controlling Authority
Benefits in case of Provisional Pension.

14 Option for medial facilities after retirement By Retiree

15 Consent for Effecting Rent/Panal Rent if residing By Retiree
in nigam accommodation
(B) ADDITIONAL DOCUMENTS IN CASE OF DEATH

16 Death Certificate By wife or Legal heirs of the

deceased employee
17 Workman Compensation Certificate By Controlling Authority

18 Affidavit of Widow on PS-5 By wife or Legal heirs of the

deceased employee
19 Affidavit of Major Children forgoing their By Family member or Legal heirs
DCRG Share on PS-6. of the deceased employee

(C) DOCUMENTS IN CASE PROVISIONAL PENSION

20 Order for Provisional Pension By Controlling Authority
Undertaking for not claiming interest on delay By Retiree
21 amount of pension etc.
 From Pen-1
[See rule 41 (2)]

Nomination for DCRG if the Government employees has a family or has not a family at that
time.

I, ____________________ working as ____________________________ has a family the

detail of which is as under:-

Sr Name of the DOB Relationship with Adhhar Remarks

No. members of family the Govt. Card No.
employee
1
2
3
4
5

I, hereby nominate the following person(s) who is/are member(s) of my

family or who is/are not member(s) of my family, and confer on him/them the right or
receive any gratuity the payment of which shall be sanctioned by Government in the event
of my death while in service and the right to receive on my death to the extent specified
below, any DCRG which having become admissible to me in case of death while in service
or death after retirement before the receipt of DCRG:-

Original nominee(s) Alternate nominee(s)

Name and Relation Age Amount or Name, address and relationship, Amount
address of ship with share of age of the person(s), if any, to or share
the the gratuity whom the right conferred on the of
nominee(s) Govern payable to nominee shall pass in the event gratuity
ment each of the nominee predeceasing the payable
employe Government employee or the to each
e nominee dying after the death
of the Government employee
but before receiving payment of
gratuity.

2. Number of persons (in words) as Original nominee: ______________________

3. Number of persons (in words) as Alternate nominee: ______________________
4. This nomination supersedes the nomination made by me earlier on
___________________ which stands cancelled
5 Strike out which is not applicable.
6. The amount/share of the DCRG shown in column No.4 and 6 shall cover the whole
amount of DCRG.
Dated this __________________ day of ______________20 at ____________________.

Signature of Government employee

Witness:
Sr. No Name Full Address Signatures
1
2
 (To be filed in by the Head of Office)

Nomination by ________________ Signature of Head of Office________________

Designation _________________ Date __________________________________
Office________________________ Designation_____________________________
Acknowledgement by the Head of Office regarding receipt of nomination form
To
________________________
________________________
________________________

Sir,
In acknowledging the receipt of your nomination, dated the
_________________/cancellation, dated the _______________ of the nomination made
earlier in respect of Death-cum-Retirement Gratuity in Form ________________, I am to
state that it has been duly signed on record.

Signature of Head of Office

(with date and stamp of Office)

Note:- The Government employee is advised that it shall be in his interest if copies of the
nominations and the related notices and acknowledgements are kept in safe
custody, so that they may come into the possession of the beneficiaries in the event
of his death.

*******
 Form Pen-2
[See Pension Rule-71]
Particular to be obtained by the Head of Office from the retiring Uttar Haryana
Bijli Vitran Nigam employees one year before his retirement on superannuation
or from the family of deceased Government employees within one month from
the date of death.
Paste one passport
size joint photograph or
photograph of
widow/widower duly
attested by Head of
office

1 Name of the Government employee

2 Designation

3 Gender

4 Department/Office

5 Date of birth

6 Date of Retirement
Or
Date of Death, in case of death while in
service
7 Present address

8 Address after retirement

9 Details of the members of the family as on

Sr Name of the DOB Relationship Adhhar Personal Remarks

No. member of family with the Govt. Card Identification
employee No. Mark
1

10 Whether pension to be drawn through

bank or UHBVNL office
11 Enclose the following documents:-
(i) Two slips of specimen signature to be
submitted by Head of Office or any gazette
officer authorized by him
(ii) Four copies of passport size joint
photographs of the Government employee
with spouse (to be attested by Head of
office or any gazette office authorized by
 him)
11 Option for commutation of pension:
Fraction of pension proposed to be
commuted:

Place____________________ Signature of Government employee

Dated the________________ Or

Family member of the deceased

Government employee

Acknowledgement

Received from Shri/Smt._________________________ (Name and former designation)

application in form Pen-2 complete in all respects for the calculation of
pension/DCRG/Commutation of pension etc.

Place:____________________ Signature of Head Office

Date_____________________ (with Stamp)

____________________________________
5 Any subsequent change of address should be informed to the Head of Office & Chief
Account Office, UHBVN, Panchkula.
 Form Pen-3
Paste one passport
(see rule-75) size joint photograph
duly attested signature
& Stamp of attesting
Form for Assessing Pension/Family Pension, authority should be on
Commutation of Pension and DCRG the photographs
To be sent in duplicate to the Chief Accounts Officer/Pension,
UHBVN, Panchkula.

1 Name of the Government employee

2 Sex
3 Aadhaar Card Number
4 Father’s Name
5 Name of Wife/Husband
6. Date of Birth
7. Marks of identification of Government
Employee
8. Present residential address of the
Government employee alongwith Mobile
phone number
9. Address after retirement alongwith at
the time of retirement:
10 Particulars of the post held at the time
retirement
(a) Department
(b) Name of the office
(c) Post last held and Group of the
post
(d) Pay scale of the post
11 Class of Pension applicable
12 Date of Joining of service
13 Date of ending of service
14 Particulars relating to military
service/past service, if any, allowed to
be counted by the competent authority
towards civil pension
15. Total length of service
16 (i) Period of foreign service if any
(ii) Whether pension contribution has
been received for the above said
period
17 Periods of Non-qualifying service
From To YYYY MM DD
(a) Interruption in service condoned
under rule 14 (2)
(b) Extraordinary leave not qualifying
 for pension
(c) Period of suspension not treated
as qualifying service for pension
(d) Any other service not treated as
qualifying service for pension
(e) Total period of non-qualifying
service.
18 Net qualifying service (Column 15-17)
terms of completed six monthly periods
i.e. of three months and above is
treated as completed six monthly
period.
19. Detail of period, if any, treated as duty
in case of a Government employee who From _____________ to _________
have been reinstated after having been (_________Y________M_______D) order
suspended, compulsorily retired, No._______________ dated __________
removed or dismissed from service.
20 Emoluments at the time of retirement:-
(a) Last drawn emoluments (actual)
(b) Last emoluments (notional) if any
(c) Emoluments reckoned for
pension and family pension
(d) Emoluments reckoned for death-
cum-retirement gratuity
Note1.- See also the definition of Emoluments for the purpose of Pension/DCRG/Family
Pension.
Note:2. If the officer was on foreign service immediately preceding retirement, the notional
emoluments which he would have drawn under Government but for being on foreign
service be reflected against (a) above.
21 Date of receipt of Form Pen-2, duly
complete in all respects from the
Government employee.
22 Proposed Pension :-

______________ X ______________=
2 10
22 Proposed Pension :-

______________ X =
4
23 Proposed family pension:-
(a) Ordinary Family Pension: Pay Last DrawnX30%
(Subject to Minimum and Maximum limit as per rule)
(b) Enhanced Family Pension: Equal to 50% of last emoluments in case of death
while in service QR Equal to retiring pension in case
of death after retirement before attaining the age of
65 years) (Subject to minimum and maximum of limit
of enhanced family pension as per rule 49)
25. The amount of the family pension becoming payable to the family of the deceased
Government employee, if death takes place after retirement.
(a) before attaining the age of 65 years Rs.
(b) after attaining the age of 65 years Rs.
Sr No. Name of the member of DOB Relationship with the Adhhar Card No.
family Govt. employee
1.
2
3
4
5
26 Date from which pension is to
commence
27. Proposed amount of provisional
pension, if departmental or judicial
proceeding instituted against the
Government employee are pending at
the time of retirement.
28. Details of Government dues recoverable out of DCRG:-
(a) License fee for the allotment of
Government accommodation
(See rule 72)
(b) Other dues referred to in rule 73
29 Whether valid nomination made for
DCRG subsists , if yes, enclose the copy
thereof.
30 Commutation of pension if applied before retirement or within one year after retirement.
(a) The portion of pension to be
commuted:
(upto 50% of pension for Judicial
Officers and upto 40% of pension
for others.)
(b) Commuted value of pension=
(portion of pension to be
commuted X Factor from table
under rule 96X12)
 (c) Amount of residuary pension
after deducting commuted
portion of pension (Sr.No.22-
30(a)]
31 (i) Place of payment of
Pension/DCRG/Commutation in
UHBVN

(ii) Bank Account No.

(iii) Unique Payee Code
32 Location Code DDO
33 Particulars of Pension Sanctioning Authority:-
(i) Designation
(ii) Office Address
(iii) Contact Number

Place_____________ Signature of the Head of Office

Date______________ (With date and stamp of office)
 EPF/CPF CERTIFICATE

(Applicable in case of retiree)

Certified that Sh. ______________________S/o Sh.___________________, working

as__________ under________________________________________, due to retire on

___________________________, is not member of EPF/CPF scheme.

Signature of
Drawing & Disbursing Officer
 Specimen Signature of husband and wife.

Specimen Signature of Specimen Signature of

Sh. _________________ Smt. __________________

W/o Sh.________________

1. 1.

2. 2.

3. 3.

Identification Mark and Height

IDENTIFICATION MARKS OF SH. …………………………………………………………………

1. Height : ………………………………………………………………………

2. Identification : ………………………………………………………………………

IDENTIFICATION MARKS OF SMT. …………………………………W/o………………………………..

1. Height : ………………………………………………………………………

2. Identification : ………………………………………………………………………
 Undertaking

I, Sh. ………………………. S/o Sh………………………… working as…………….. in the O/o

………………………………………………. Retiring on …………………………… hereby tendered my

undertaking in favour of UHBVNL, Panchkula if any excess amount will be given to me on

account of Gratuity & Commutation can be recovered from any pension in future.

(________________)

Attested
Joint Photographs of Sh…………………………………………….. retiring

on……………………………. And his wife Smt…………………………………. are given below:-