ENCLOSURE-'D'

NOMINATION FOR PAYMENT OF DEATH-CUM-RETIREMENT GRATUITY

(To be furnished by the Emplyee)
I hereby nominate the person mentioned below, who are members of my family and confer on them the right to receive, to the extent specified below, any gratuity that may
be sanctioned by Government in the event of my death while in service and the right to receive no my death, to extent specified below, any gratuity which having become
admissible to me on retirement may remain unpaid at my death:

Contingencies on Name, Address & relationship of the person or

Amount of
the happening of persons, if any, to whom the right conferred on
Relationship Age(Date of share of Amount of share of gratuity
Name & Address of Nominees which the the nominee shall pass in the event of nominee
with employee Birth) gratuity predeceasing the employee or the nominee payable to each
nomination shall
payable to each dying after the death of the employee but
become invalid before receiving payment
1 2 3 4 5 6 7

* This nomination supersedes the nomination made by me earlier on which stands cancelled.

Dated this day of 20 at

Witness to Signature: Name and Address (Signature of employee)

(1).

(2).
Note: (1) The employtee shall draw lines across the blank space below the last entry to prevent the insertion of any name after he/she has signed.

(2) Fourth column should be filled in so as to cover the whole amount of gratuity.
Sub-Inspector of Schools
(3) The amount/share of gratuity shown in last column to cover the whole amount/share payable to the original nominee. Bagnan East Circle, Howrah

* Strike out, if not applicable

District Inspector of
Date: Schools(P.E), Howrah
 TO BE FILLED IN BY THE PETITIONER/SUB INSPECTOR OF SCHOOLS

List of Family Members of the Pensioner/Petitioner

Address of Deceased Relationship with
Sl.No. Name of the Member Date of Birth
pensioner/Pensioner the Pensioner

Signature of Pensioner/Family Pensioner

Authenticated by (With Office Seal)

Date:

Signature of the Sub-Inspector of Schools

Bagnan East Circle, Howrah

Countersign of D.I./PSA(With Office Seal)

 ENCLOSURE - 'E'
NOMINATION FOR PAYMENT OF LIFE TIME ARREAR OF PENSION
(To be furnished by the Employee)
Pension Disbursing Authority/Head of Office
Name of Bank / Treasury/ Accountant General, West Bengal
(Place) HOWRAH

I hereby nominee the person named below under rule 5 of the payment of Arrear Pension (Nominations) Rules, 1986.
(Name of the Pensioner in Capital Letters)
Relationship If nominee is minor, Name and Address of Relationship Date of Name and Address of Contingencies on the

Date of Birth
with name and address of other nominee incase the with Birth if person who may happening of which the
pensioner persons who may nominee under Col.(I) pensioner the other receive the pension Nomination shall becomes
Name and Address of Nominees
receive the said predeceases the nominee during the other Invalid
pension during the pensioner is minor nominee's minority
nominee's minority
(1) (2) (3) (4) (5) (6) (7) (8) (9)

Place: Date:
witness to Signature : Name & Address :
(1).
(2).
Signature of the Pension Disbursing Authority/ Head of Office Signature (or thumb impressionnif illitarate) of pensioner and address
Acknowledgement to be sent by the Pension Disbursing Authority/ Head of Office
Certified that application /nomination hes been received from Sri / Smt Head/Asstt. Teacher of
School.
Whose address (Residence) is

Signature of the Sub-Inspector of Schools District Inspector of Schools (P.E), Howrah

Bagnan East Circle, Howrah
Three copies of Photographs (Single/Joint) to be stapled below. The photo should have
the name(s) of the pensioner(s) & be attested on the frontside by Group ''A'' Officer/ Sub-
Inspector of Schools.

Paste joint Photograph

Paste joint Photograph

Paste joint Photograph

Three specimen signatures of the pensioner to be given below duly attested by Sub-
Inspector of Schools/ gazetted officer.

Name of the Pensioner/Family Pensioner:

(In Block Letters)

Signature Attested
Signature

Signature

Signature

Signature Attested
Signature

Signature

Signature

Signature Attested
Signature

Signature

Signature