esa 49 eiseaez089) (ro becompise by the Office / Department recsiving the appliation for pension [Ssstry/Diision/Deparment [ PesounsiNe ‘ans of Gaver Servant Fathers Musband Nene 2 Sesion on uy [CONIC No of Govt Servant I Se ae Lat i | Dale of Birth (as_per service book) zt | “Fniry ino Govt, Service z Se! [Bate oF Retent/ Desi ____Nume of family pensioner = i Pees, dot BakAreNo. Bank Braach & Cole (Ciass of Pension Emote Superauniston Bisley Ts Reuing Usual nee ie. Teal Sr PostAllOW Re ‘Tenet af Condonation| Compalsany Special Pap Re SOT TUneA horned Abvence ‘Compensation Personal Pay [Rs | [RetGuaiivag senies Satan aiiheaion ay ‘| amily Pension Total Rs. Pension Family Pension Rs. Other Allowances () ii), fecene Git. Pension to be commuted es | Age Next Birthday (or 60 in case of Superannuation) | Rate of commuted value for every one rupee [-Commotatjon/Gratuit Commutation to be WithhelaGitany) Pension after commutation s UNDERTAKINGS BY THE PENSIONER: do hereby undertake: i) ‘That Government may, at any time from the issue of Pension Payment Order, recover any: of iis ues or overpayments from the pension granted to me (Under Artite 906 (E) of CSR) {iy That I have neither applied for nor received any pensior/comimutation/eratuty in respect of aay portion of the service included in this application and in respect of which pension/gratuity is claimed. herein, nor shall I submit any application hereafter without quoting a reference to this ‘application and to the order which may be possed thereon (Article 91 of CSR) IBICATES BY PEN .NCTIONING AUTHORITY i) No inquiry is pending against him/her. ii) Outstanding recovery {No. }/{¥es. }, Ifyes, provide full derail, iti) Satisfaction about retiring employee's service, if No, it has been decided that full pension and/or sratuity granted by Audit/Aceounts Officer be reduced under the rales as . __ Amount/Pereentage reduction in pension, Gratuity iv) The payment of pension/gratuity may commence from wick ¥) All the requisite documents as per CGA circular are attached Nine tnd Sgntur eto Signature oftexdofOfelDepurmem _Pnsian Sanding Authority , Meneeigeton cone Nant Desiiaion Date cotannan OMENS es aaee