1

COMBINED AAPLICATION FORM FOR GENERAL PROVIDENT FUND FINAL

CLOSURE AND FAMILY PENSION
PART -1
FOR DEATH WHILE IN SERVICE/EXTENSION OF FAMILY PENSION CASES
(To be sent in Duplicate)

1. Name of the Government : M.MALARVILI

Employee
(IN CAPITAL LETTERS)
2. Designation & Department : Special Tahsildar (LA),
NH 85 (New), Unit - 4, Usilampatti
Revenue Department
3. Employee Identification No : 41020272030
4. G.P.F. No with Departmental : 123240 GA
Suffix
5. Date of Death : 08.10.2020.
6. Date of Retirement in case of : Death while in Service
Death after retirement
7. Name of the Applicant : Thiru. Sathiyaseelan,
Husband
8. Religion : Piramalai Kallar - Hindu
9. Date of Birth in case of Minor : Does not arise
with Proof
10. P.P.O. No. allotted by A.G.s : New case
Office (Applicable only for
Revision Cases)
11. Permanent Account No. for : EWRPM1484H
Income Tax (PAN) Malarvili
12. Aadhaar No : 2846 0615 6931
13. Date of Birth : 24.05.1973
14. Date of Joining : 20.10.1994
15. Date of Retirement : 31.05.2032
16. Name of Applicant : Thiru.Sathiyaseelan,
17. Relationship with Government : Husband
Employee
 2

18. Mobile No : 9894687712

19. Date of Birth : 26.05.1973
20. Permanent Account No. for : AQCPS9786M
Income Tax (PAN)
21. Aadhaar No : 3022 6802 4605
22. Religion : Hindu - Indian
23. Residential Address with PIN : Thiru.Sathiyaseelan,
Code No S/o.PD.Jayaseelan (late),
38, Mangayarkarasi School Teacher’s
Colony, 3rd Street, Puttu Thoppu,
Madurai - 625 016.
24. Place of Payment of Family : Madurai District Treasury.
Pension
25. Bank Account No: (Single A/C) : 169901000001857
26. Name of the Bank : INDIAN OVERSEAS BANK
27. Branch with Postal Address : INDIA OVERSEAS BANK
MANINAGARAM
Brach Code: 1699
28. MICR Code (It is a 9 digit code : 625020015
that helps identify a particular
bank branch)
29. IFSC Code of the Branch (IFSC : IOBA0001699
is a unique 11 digit number
which is a combination of
alphabets and numerals and it
is used to transfer funds
online)
30. Are you in receipt of Family : No
Pension from any other source
31. If Yes, P.P.O. No and Treasury : P.P.O. No -
from which it is drawn may be P.P.O/
furnished District Treasury/ -
sub Treasury
 3

32. List of Family Members :

Whether
S. Relation Marital Date of Handicapped
Name
No ship Status Birth Age /mentally
Retarded
1. Sathiyaseelan Husband Widower 26.05.1973 No
2. Abirami Daughter Unmarried 01.04.2002 No
3. Jeyashree Daughter Unmarried 20.12.2007 No
33.
Name of Guardian in case of Mentally : Does not arise
retarded Children
34. Death Certificate/Legal Heir : Enclosed

Certificate/Proof of date of Birth in

case of Minor Children (Enclose

separately)

35. If the applicant is second wife Date of : Does not arise

Marriage with proof and details of

first wife and children born through

both wives may be furnished (copy of

Death Certificate/Court orders from

divorcing the first wife, as the case

men be, to be furnished)

36. Details of Temporary Advance/Part :

Final Withdrawal Sanctioned in the

last 12 Months (If no debit is drawn

in last 12 months, the details of last

debit drawn should be specified.

 4

PART-II

TO BE FILLED IN BY THE DEPARTMENTAL OFFICER

1. A.G’s Office Reference No. in : Does not arise

which the proposals were
2. a) Name of the Government : Tmt.M.Malarvili
Employee
b) Post held : Special Tahsildar (LA)
c) Office/Department : O/o The Special Tahsildar (LA),
NH 85 (New) Unit -4, Usilampatti.
Revenue Department.
3. Date of Beginning of Service : 20.10.1994
4. Date of Ending of Service. : 08.10.2020 (Died while in Service)
5. Gross Qualifying Service. : 25 Years 11 Months
6. Non-Qualifying Service. : 1. 09.05.2000 to 11.05.2000 3 days
2. 13.07.2000 1 day
3. 06.02.2001 to 08.02.2021 3 days
4. 25.07.2001 1 day
5. 23.10.2002 to 01.11.2002 10days
Total 18 days
7. Additional Qualifying Service :
under Rule 27 / Due to
Voluntary Retirement
/Contingent Service /
Military Service.
8. Net Qualifying Service. : 25 Years 11 Months (52 Half years)

9. Total Period of Military : -

Service and Military Pension
/ Gratuity Received. (Details
of remittance to be
furnished separately).
10. Scale of Pay / Level No : Rs.37700-119500
Level 20
11. Pay Last Drawn (Special : Pay : Rs.58,800
Pay, Personal Pay drawn if
any to be shown separately)
as on 08.10.2020.
 5

12. Class of Pension applicable : Civil - Superannuation Pension

13. Whether any charges are : Nil.
pending against the
Government Employee? If
so, furnish the
details thereof
14. Office served in the last 3 :
years.
PERIOD
TO OFFICE IN WHICH SERVED
FROM
Tahsildar (SSS),
14.07.2016 12.08.2017
Thirumangalam
13.08.2017 20.08.2017 Transit Period
Assistant Manager,
21.08.2017 08.11.2018
Tasmac Ltd., Madurai North.
09.11.2018 15.11.2018 Transit Period
Special Tahsildar (LA),
16.11.2018 27.11.2019
NH 85 (New), Unit -4 Usilampatti.
28.11.2019 12.12.2019 EL 15 days
Un Earned Leave on Medical Certificate
13.12.2019 11.03.2020
90 days
Un Earned Leave on Medical Certificate
12.03.2020 31.08.2020
173 days
Un Earned Leave on Medical Certificate
01.09.2020 08.10.2020
38 days
15. a) Drawing Officer for G.P.F. : Special Tahsildar (LA),
With Full Postal Address NH 85 (New), Unit- 4, Usilampatti
and PIN Code.
b) Phone No. of the Office : -
with STD Code.
c) e_ mail ID / FAX :
18. Treasury / PAO for G.P.F. : Sub Treasury, Usilampatti
19. a. Drawing Officer for : Special Tahsildar (LA),
D.C.R.G. with Full Postal NH 85 (New), Unit- 4, Usilampatti
Address and PIN Code
b. Phone No. of the Office : -
with STD Code.
c. e_ mail ID / FAX : -

22. Treasury / PAO for D.C.R.G. : Sub Treasury, Usilampatti

23. Particulars of Last G.P.F. :
Deduction [Last 12 Months
Details].
 6

Total
Date & Sub-
Pay Recover Amount
GPF Sub- Place of Account Voucher
for y Of Cr.
Scripion Paymen of No.
Month /Refund Schedule
t Account
.
(1) (2) (3) (4) (5) (6) (7)

----

24. Details of Temporary :

Advance /Part Final
Withdrawal Sanctioned in
the last 12 months (If no
debit is drawn in last 12
Months, the details of last
debit Drawn should be
specified)

Month Amount Voucher No. Date of Payment

(1) (2) (3) (4)

CERTIFICATE
It is certified that:

1. All the particulars furnished above have been fully verified with reference
to office records and are found correct.

2. Advance/withdrawal from GPF was granted during the last 12 months

as detailed in column 18 above.

3. No Charges are pending/Charges are pending against the individual.

(Details furnished separately)

4. Provisional Pension not paid/Provisional Pension paid (Details furnished

separately)

5. Conditions laid down in Rule 11 (2) and Rule 11 (3) of the Tamil Nadu
Pension Rules, 1978 have been satisfied and the same has been recorded
in Service Book.

Special Tahsildar (LA)

National Highways 785, Unit -1,
Madurai - Natham
 7

CHECK LIST / LIST OF ENCLOSURES

1. Service Book(s). [No. of Volumes] : Enclosed

2. Recent Joint Passport size Photo with : Yes. Enclosed
Spouse, Specimen Signature/ left hand
thumb impression (in the case of
illiterate) and Descriptive Roll of the
Government Employee, all in triplicate,
duly attested [furnished in the
Annexure].
3. Sanction order in respect of Non- : Does not arise.
Government Aided Educational
Institution cases and Missing
Employee.
4. In case of Teachers, Non-Employment/ : Does not arise.
Re-employment Certificate.
5. Copy of First Information Report in : Does not arise.
respect of Missing Employee.
6. Nomination for General Provident Fund :
(GPF).
7. Nomination for Death cum : Enclosed
Retirement Gratuity (DCRG).
8. Nomination for Life Time Arrears of : Enclosed
Pension
9. Nomination for Commutation of :
Pension (in duplicate).
10. Medical Certificate in original in Form : Does not arise.
23 as prescribed in Rule 36 of TNPR for
invalidation cases issued by Medical
Board.
11. Certificate of Medical Opinion of the : Does not arise.
Doctors for admitting Commuted Value
of Pension in the cases of Invalidation
and Compulsory Retirement cases.
 8

12. Ratification Order of Government for : Does not arise.

waiving any shortfall in notice period
due to sanction of Extraordinary Leave
with / without Medical Certificate (in
respect of Voluntary Retirement cases).
13. Military Verification Certificate. : Does not arise.
14. Copy of the Chalan for refund of : Does not arise.
Gratuity received with Interest for
Military Service.
15. Copy of Proceedings issued in the case : Does not arise.
of Compulsory Retirement / Voluntary
Retirement /Invalidation cases.
16. Copy of Government Order : Does not arise.
imposing cut in Pension issued on
completion of Disciplinary
Proceedings / Dropping the Charges.
17. Copy of Adoption Deed, in case of : Does not arise.
adopted children.
18. Copy of Medical Certificate in the case : Does not arise.
of Mentally Retarded Children /
Handicapped Children.

Special Tahsildar (LA)

National Highways 785 Unit -1,
Madurai - Natham

Place :
Date :

INSTRUCTIONS

1. Please send the application in DUPLICATE.

2. Please fill up all columns in capital letters.
3. Incomplete application will not be processed.
4. Annual Account Statement of GPF need not be sent.
5. Last Fund deduction particulars mean deduction to GPF
Before stopping recovery.
6. For arriving at the Commuted value of Pension, dated
Signature of the Government servant in Part I is compulsory.
 9

CALCULATION SHEET FOR PENSIONARY BENEFITS

1. Name of the Govt. servant : Tmt.M.MALARVILI

2. Designation : SPECIAL TAHSILDAR (LA)
3. Date of Birth : 25.04.1973
4. Date of entry to service : 20.10.1994 FN
5. Date of Regularisation : 20.10.1994 FN
6. Date of Retirement : -
7. Date of Death : 08.10.2020
8. Length of Qualifying Service : Year Month Days
25 11 00 (52 Half Years)
9. Name of the Applicant for : Thiru.J.SATHIYASEELAN
Family Pension
10 Relationship of Applicant : Husband
.
11 Emoluments for Family Pension : Pay Rs.58800/-(Level 20/Cell 16)
. in Revised Scale of Pay as on Level 20/ Rs.37700-119500
08.10.2020
12 I. (i) FAMILY PENSION : Rs.29400/- From 09.10.2020
(ENHANCED RATE)
. to 07.10.2030
58800
Family Pension : Rs.
2
= Rs.29400/-
(ii) FAMILY PENSION : Rs.17640/- Thereafter
(NORMAL RATE)
58800 x 30
Family Pension: Rs.
100

= Rs.17640/-
II. DCRG : Pay Rs. 59800 (58800+1000 SP)
Emolument of DCRG as on DA 17% Rs. 9996
08.10.2020 Total Rs. 69796
69796 x 52 : Rs.18,14,696/-
DCRG Eligible :
2
= Rs.18,14,696/-

Special Tahsildar (LA)

National Highways 785 Unit -1,
Madurai - Natham
 10

Details of Service in respect of Tmt.M.Malarvili,

Special Tahsildar (LA), NH 85 (New) Unit-4
Who died while in service on 08.10.2020

S. Post Held Office in

Post Held Y M D
No From To which Served
1. 20.10.1994 31.07.1997 Typist Taluk Office, 0 09 12
VilathiKulam 2
2. 01.08.1997 23.12.1997 Typist Taluk Office, - 04 23
Tuticorin
3. 24.12.1997 20.01.1998 Typist Survey Training - - 27
@ Orathanadu
Training
Institute
4. 21.01.1998 27.01.1998 Typist Survey - - 07
Settlement
Training
5. 28.01.1998 15.05.1998 Typist Collector’s - 03 18
Office,
Tuticorin
6. 16.05.1998 17.05.1998 Typist Holiday - - 02
permission
(Prefix the
Holiday)
7. 18.05.1998 22.05.1998 Typist EL on 5 days - - 05
8. 23.05.1998 24.08.1998 Typist Holiday - 03 02
Permission
(Suffix the
Holiday)
9. 25.08.1998 - Typist Transit 1 day - 01 -
10. 26.08.1998 13.08.2000 Typist Taluk Office, 0 11 18
Madurai North 1
11. 14.08.2000 16.08.2000 Assistant Taluk Office, - - 03
Madurai North
12. 17.08.2000 31.12.2000 Typist Taluk Office, - 04 11
Madurai North
[09.05.2000 to
11.05.2000
3 days,
13.07.2000 – 1
day
Totally LLP for
4 days)
13. 01.01.2001 04.01.2001 Typist Transit 4 days - - 04
 11

14. 05.01.2001 12.06.2001 Typist Taluk Office, - 05 08

Vadipatti
[ 06.02.2001 to
08.02.2001
3 days LLP)
15. 12.06.2001 24.07.2001 Typist D.B.C.W.O. - 01 13
AN Office, Madurai
16. 25.07.2001 - Typist Strike period 1 - - 01
day LLP
17. 26.07.2001 31.07.2001 Typist D.B.C.W.O. - - 06
Office, Madurai
18. 01.08.2001 03.08.2001 Typist 3 days EL - - 03
19. 04.08.2001 05.08.2001 Typist 2 days Suffix - - 02
the Holidays
20. 06.08.2001 08.08.2001 Typist Duty Period - - 03
21. 09.08.2001 24.08.2001 Typist 16 days EL - - 16
22. 25.08.2001 31.03.2002 Typist D.B.C.W.O. - 07 07
Office, Madurai
23. 01.04.2002 29.06.2002 Typist Maternity Leave - 03 -
for 90 days
24. 30.06.2002 31.07.2002 Typist UEL on MC 32 - 01 02
days
25. 01.08.2002 23.08.2002 Typist UEL on MC 23 - - 23
days
26. 24.08.2002 30.09.2002 Typist EL on 38 days - 01 08
27. 01.10.2002 12.11.2002 Typist District - 01 13
Adi Dravidar
and Tribal
Welfare Officer,
Madurai
28. 13.11.2002 20.12.2002 Assistant District - 01 08
Adi Dravidar
and Tribal
Welfare Officer,
Madurai
[23.10.2002 to
01.11.2002
10 days LLP]
29. 20.12.2002 10.04.2003 Assistant Taluk Office, - 03 21
AN Madurai North
30. 11.04.2003 30.06.2003 Typist Taluk Office, - 02 18
FN Madurai North
31. 30.06.2003 - Typist Transit Period 1 - - 01
day
32. 01.07.2003 - Assistant Taluk Office, - - 01
 12

Melur
33. 02.07.2003 24.07.2003 Assistant Strike period 23 - - 23
days treated as
Duty
34. 25.07.2003 31.07.2004 Assistant Taluk Office, 01 - 07
Melur
35. 01.08.2004 03.08.2004 Assistant EL 3 days - - 03
36. 04.08.2004 10.08.2004 Assistant Transit 7 days - - 07
37. 11.08.2004 16.11.2004 Revenue Madurai North - 03 06
Inspector Taluk
[Arumbanoor
Firka]
38. 17.11.2004 - Revenue Transit 1 day - - 01
Inspector
[Arumbanoor
Firka]
39. 18.11.2004 22.09.2006 Revenue Vadipatti Taluk 01 10 05
Inspector
[Sholavandan]
40. 23.09.2006 07.11.2006 Revenue Fundamental - 01 15
Inspector Training@
[Sholavandan] Bhavani Sagar
Training
Institute
41. 08.11.2006 17.01.2007 Revenue Vadipatti Taluk - 01 10
Inspector
[Sholavandan]
42. 18.01.2007 24.01.2007 Revenue Transit 7 days - - 07
Inspector
[Sholavandan]
43. 25.01.2007 13.12.2007 Assistant D.B.C.W.O. - 10 20
Office, Madurai
44. 14.12.2007 19.12.2007 Assistant EL 6 days - - 06
45. 20.12.2007 18.03.2008 Assistant Maternity Leave - 03 -
90 days
46. 19.03.2008 07.05.2008 Assistant UEL on MC 50 - 01 29
days
47. 08.05.2008 31.05.2008 Assistant UEL on MC 24 - 03 29
days
48. 01.06.2008 12.06.2008 Assistant EL on 12 days - - 12
49. 13.06.2008 10.07.2009 Assistant Taluk Office, 01 01 08
FN Madurai South
50. 10.07.2009 16.07.2009 Assistant Transit 7 days - - 07
51. 17.07.2009 21.06.2011 Assistant Taluk Office, 01 11 05
Vadipatti
52. 22.06.2011 27.01.2012 Zonal Deputy Taluk Office, -- 07 06
 13

Tahsildar Vadipatti
53. 28.01.2012 27.03.2012 Zonal Deputy Police Training - 01 30
Tahsildar
54. 28.03.2012 17.05.2013 T.S.O. Vadipatti Taluk 01 01 20
FN (Deputy
Tahsildar)
55. 17.05.2013 03.03.2014 Zonal Deputy Vadipatti Taluk - 09 17
Tahsildar
56. 04.03.2014 29.07.2014 Special Special - 04 16
Tahsildar Tahsildar (LA),
Sipcot Unit-I,
Thirumangalam
57. 30.07.2014 13.11.2014 Tahsildar Madurai East - 03 14
(SSS) Taluk Office
58. 14.11.2014 13.03.2015 Tahsildar Magistrate - 03 30
(SSS) Training Period
59. 14.03.2014 12.04.2015 Tahsildar EL 30 days 01 - 29
(SSS)
60. 13.04.2015 19.04.2015 Tahsildar Transit 7 days - - 07
(SSS)
61. 20.04.2015 13.07.2016 Tahsildar Usilampatti 01 02 24
(SSS) Taluk Office
62. 14.07.2016 12.08.2017 Tahsildar Taluk Office, 01 - 29
Thirumangalam
63. 13.08.2017 20.08.2017 Tahsildar Transit 7 days - - 07
64. 21.08.2017 08.11.2018 Assistant TASMAC Ltd., 01 02 08
Manager Madurai North
(Retail Sales)
65. 09.11.2018 15.11.2018 Assistant Transit 7 days - - 07
Manager
(Retail Sales)
66. 16.11.2018 27.11.2019 Special Special 01 - 12
Tahsildar (LA) Tahsildar (LA),
NH 85 (New)
Unit-4,
Usilampatti
67. 28.11.2019 12.12.2019 Special EL 15 days - - 15
Tahsildar (LA)
68. 13.12.2019 11.03.2020 Special UEL on MC 90 - 02 29
Tahsildar (LA) days
69. 12.03.2020 31.08.2020 Special UEL on MC 173 - 05 19
Tahsildar (LA) days
70. 01.09.2020 08.10.2020 Special UEL on MC 38 - 01 08
Tahsildar (LA) days
 14

MEMORANDUM OF SERVICE

Year Month Day

Date of Ending of Service 2020 10 08
Date of Beginning of Service 1994 10 20
Gross Qualifying service 25 11 18
ADD: Addition Qualifying Service -Nil-
DEDUCT: Non Qualifying Service
LLP
1) 09.05.2000 to 11.05.2000 3 days
2) 13.07.2000 1 day
00 00 18(-)
3) 06.02.2001 to 08.02.2001 3 days
4) 25.07.2001 1 day
5) 23.10.2002 to 01.11.2002 10 days
Total 18 days
_____________________________
Net Qualifying Service 25 11 00
(52 Half Service)

Special Tahsildar (LA)

National Highways 785 Unit -1,
Madurai - Natham
 15

Special Allowance Arrear Details

Sl. Name & Special

Month Total
No Designation Allowance

1 Tmt. M. Dec-17 1000 1000

Malarvizhi.,
Tahsildar
2 Jan-18 to Oct-18 (10 Months) 10000 10000
Tasmac
(Madurai
3 North) Nov-18
267 267
(01.11.2018 to 8.11.2018)

4 Tmt. M. Nov-18
733 733
Malarvizhi., (09.11.2018 to 30.11.2018)
Spl
5 Tahsildar(LA) Dec-18 1000 1000

6 Jan-19 to Dec-19
12000 12000
(12 Months)

7 Jan-20 to Sep-20
9000 9000
(9 Months)

8 Oct-20
258 258
(01.10.2020 to 08.10.2020)

TOTAL 34258 34258

Rs. 34,258/- (Rupees Thirty Four Thousand Two Hundred and Fifty Eight
Only)

Special Tahsildar (LA)

National Highways 785 Unit -1,
Madurai - Natham
 16

Calculation Sheet
1 Special Allowance Arrear 34,258
Dec 2017 to Oct 2020

2 Increment Arrear 15,912

01.01.2020 to 08.10.2020

3 Sep 2020 Salary 71,296

4 Oct 2020 20,254

(01.10.2020 to 08.10.2020) Salary

5 GPF 3,88,829

6 Unlearn Leave Salary 2,16,888

180/2= 90 Days
3 X 72296 (Basic pay+DA+HRA+MA+SP)

7 Earn Leave 240 Days 5,78,368

72296 X 8 Months full salary

8 DCRG 18,14,696

9 FBF 4,75,000

Total 36,15,501

Special Tahsildar (LA)

National Highways 785 Unit -1,
Madurai - Natham