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    		•
    FORMAT FOR PARTICULARS OF PENSIONER
    NOTE: You have to fill in all the items. In case a particular item is not applicable,
    please state so but do not leave the item blank.
    1. (a) Name of the Govt. Employee :  
      (b) Wife/Husband's name :  
    2.   Father's name :  
    3. (a) Address of the Govt. Employee :  
      (b) ( Present & Permanent address ) :  
    4.   Religion and Nationality :  
    5.   Present & last appointment
    ( including name of establishment) (I) Substantive (II) Officiating, if any    		 :  
    6. (a) Status of the Govt. employee (Temporary / Permanent ) :  
      (b) Whether work-charged employee ? :  
      (c) Whether a member of the G. P. Fund ( if so, whether employer's share has been refunded ). :  
    7.   Class of Pension/Gratuity applicable (Superannuation/Death/Voluntary/Pro-rate/Invalid etc. :  
    8.   Govt. under which service has been rendered (in order of employment showing the period served under each Govt. :  
    9. (a) Date of Birth of the Govt. employee :  
      (b) Date of appointment :  
      (c) Date of Retirement/Death :  
      (d) Period of Gross service :  
      (e) Period of War/Military service, if any :  
      (f) Amount and nature of Pension/Gratuity received for Military service. :  
      (g) Descriptive role :  
        i) Height :  
        ii) Identification mark :  
        iii) Thumb and finger impression- :  
    THUMB FOREFINGER MIDDLE FINGER RING FINGER LITTLE FINGER
     




    		  




    		  




    		  




    		  
    [ Persons who are literate enough to sign their names in English, Hindi or the Official Regional Language, are exempted from recording their left thumb and finger impressions ]
    10.   Non-qualifying service :  
        (a) E. O .L. without medical certificate :  
        (b) Period of suspension not to be counted towards pension etc. :  
        (c) Other non-qualifying service if any. :  
    11. (a) Net qualifying service
    (Gross service minus non-qualifying service    		 :  
      (b) Last of drawn :  
      (c) Proposed Pension :  
      (d) Proposed Gratuity/Death Gratuity :  
      (e) Proposed Family Pension, if applicable :  
    12.   Date from which pension is to be commenced :  
    13. (a) Place of payment of pension/gratuity/ (Death/retiring) /family pension :  
      (b) If payment is desired through a public sector Bank in Kolkata Corporation Area Only :  
      (c) Name of the Treasury of the Head of Office. :  
    14. (a) Whether nomination made for LTA Pension ? :  
      (b) If so, state the name of the nominee
    ( enclose the nomination paper )         		:  
    15.   For death case only
      (a) Whether nomination made for Death Gratuity ? :  
      (b) If so, state name(s) of the nominee(s), his/her/their relationship with the Govt. employee and share payable. :  
      (c) If not, state below the details of surviving family members (defined in Rule 7(1)(3)(1) of the WBS(DCRB) Rules, 1971 :  
    Statement of Family Members
    NAME DATE OF BIRTH AGE MARITALSTATUS RELATIONSHIP
     




    		  




    		  




    		  




    		  
    16. (a) Whether Commutation of Pension wanted ? :  
      (b) If so, Amount/Portion of Pension to be commuted :  
      (c) Date on which application for commutation has been received by the pension sanctioning authority (Enclose application for commutation in prescribed form ) :  
    17.   Outstanding dues of the Govt. employee.  
      (a) House Building Advance :  
      (b) Marriage Advance :  
      (c) Cycle Advance :  
      (d) Festival Advance :  
      (e) Overdraw of Pay/Allowance :  
      (f) Any other outstanding dues :  
           
        TOTAL :  
         
    18. (a) Provisional Pension Paid/to be paid if any, ( please state the rate and the period for which sanctioned) :  
      (b) Provisional Gratuity/Death gratuity paid / to be paid, if any. :  
      (c) Immediate relief paid, if any :  
    19.   Any other remarks :  
    20.   Head of Account to which pension/Gratuity are chargeable. : 2071-Pension & Other Retirement Benefits.
    21.   Date on which Govt. employee applied for pension. :  
    22. (a) Whether the Govt. employee is reemployed after retirement :  
      (b) If so, details of reemployment and fixation of reemployed pay may be stated :  
    23.   Whether the Widow/Widower is employed ( for death case only ) :  


    The undersigned having satisfied himself that the above particulars are true and that the service of the Govt. employee has been thoroughly satisfactory hereby orders the grant of full Pension/Family Pension, Death-cum-Retirement Gratuity/Service Gratuity Which may be accepted by the Accountant General as admissible under the rules.

    OR


    The undersigned having satisfied himself that the service of Sri/Smt/Kumari ___________________________________________________________________ has not been thoroughly satisfactory hereby orders that the of full Pension/Family Pension, death-cum-Retirement Gratuity/Service Gratuity which may be accepted by the Accountant General as admissible under the rules shall be reduced by the specified amount or percentage indicated below :-



    Amount or percentage of reduction in Pension / Family Pension _____________________________________________________________________________ Amount or percentage of reduction in Gratuity ______________________________________________________ The Grant of Pension / Family Pension, Death-cum-Retirement Gratuity / Service Gratuity _________________________________________________



    This Order is subject to the condition that if the amount of Pension and / or Gratuity as authorised be afterwards found to be in excess of amounts to which the pensioner is entitled under the rules, he/she shall remain liable to refund such excess.
    Dated :
    Signature and Designation of the Pension
    Sanctioning Authority




    NOTE : 1) Only the following documents are required to be submitted to the office of the Principal Accountant General (A&E), West Bengal, along with this form duly filled in :
        2) LPC/Statement of Outstanding dues.
        3) Service Book.
        4) Calculation Sheet for qualifying Service, Pension Gratuity and Family Pension.
        5) Attested passport size Joint Photograph and Specimen Signature/Left Thumb impression of the Pensioner/family Pensioner ( 4 copies each )
        6) Death Certificate/Medical Certificate ( in case of death or invalidation )
        7) Nomination regarding Arrears of Pension Nomination Rules, 1986.
        8) Application for Commutation in Prescribed Form.
        9) Fixation of Pay under the relevant ROPA Rules should be checked by the Finance Department and a certificate to that effect should be given in the Service Book, failing which the pension case is likely to be returned.
        10) In case of payment is desired in outside West Bengal this form may be submitted in duplicate.


    FORM NO - 5
    ( Form No.30 C. S. R. )
    (see rules 125, 130 and 132 )
    FORMAL APPLICATION FOR PENSION


    From : .................................................................................
    .................................................................................
    .................................................................................
    To : .................................................................................
    .................................................................................
    .................................................................................


    Sub : Application for sanction of pension.

    Sir,
    I beg to say that I am due to retire from service with effect from the .................................................. my date of birthing being .......................... I therfore request that steps may kindly be taken with a view to the pension and gratuity admissible to me being sanctioning by the date of my retirement. I desire to draw my pension from .......................................................... treasury.

    2. i hereby declare that I have neither applied for nor receive, any pension or gratuity in respect of any portion of the service qualifying for this pension and in respect of which pension and / or gratuity is claimed herein nor should I submit an application hereafter without quoting a reference to this application and the orders which may be passed thereon.
    3. I enclosed herewith :-
      i) There specimen signature of mine, duly attested,
      ii) There copies of joint passport size photographs of mine and wife, duly attested ;
      *iii) There slips each bearing my left thumb and finger impression; identification marks.
      *iv) There slips each showing particulars of my height and identification marks.
    4.   My present address is ........................................................................... and mu after will be .................................................

    ...........................................................
    ( Signature with Designation )
    Dated : ..................200......
    NOTE : Any subsequent change of address should be notofied to the Head of the office,
    * This is required only in thecase of persons who are illiterate and cannot sign their names.


    The Payment of Arrear of Pension (NOMINATION) Rules, 1986.

    FORM-A
    [ see rules 5(1) ]


    Pension Disbursing Authority / Head of Office
    Name of Bank / Treasury / Accountant General, West Bengal
    (Place)________________________________________________________________________________________
    I _________________________________________________________________________________ hereby nominate the person
    ( Name of the Pensioner in Capital Letters )

    named below under rule 5 of the payment of Arrears of Pension (Nomination ) Rules, 1986.
    *********************************************************************

    1. Name and address of the nominee :  
    2. Relationship with pensioner :  
    3. Date of birth :  
    4. If nominee is minor, name and address of person who may receive the said pension during the nominee's minority :  
    5. Name and address of other nominee in case the nominee under colum(1) predeceased the pensioer :  
    6. Relationship with pensioner :  
    7. Date of birth if the other nominee is minor :  
    8. Name and address of person who may receive the pension during the other nominee's minority :  
    9. Contigency on happening of which nomination shall become invalid :  
    Place :  
    Date : Signature ( or thumb impression if illiterate )
    and name of pensioner and address


    Witness : Signature :
        Name & Address :


    Signature of the Pension Disbursing Authority / Head of Office
    Acknowledgement to be sent by the Pension Disbursing Authority / Head of Office.
    Certified that applicant / nomination has been received from Sri./Smt. __________________________________ ( name of pensioner ) whose address is ___________________________________________.
    Place : Signature of the Pension Disbursing Authority/
    Date : Head of Office with full address.




    ANNEXURE 'A'
    ( Vide Rule 42, Part - A )
    Application for drawal of pension through public
    Sector Banks ( to be submitted in duplicate )


    To
    The Principal Accountant General ( A&E ) W.B.
    Treasury Buildings,
    Kolkata - 700001.

    Sir,
    I opt to draw my pension through Public Sector Banks and give below necessary particulars to enable you to make arrangements in this regard :-
    1. Particulars of pensioner  
      a) NAME :-
      b) P.P.O. NO. :-
      c) PRESENT ADDRESS :-
    2. Particulars of authorised Public Sector Banks  
      a) NAME :-
      b) BRANCH
    ( Where payment desired )    		 :-
    3. *Pensioner's S.B. Account No. at the branch to which pension is to be credited. :-


    Yours faithfully,

    __________________________________
    ( Pensioner )
    Place :
    Date :
    * ( Note 'Joint' or 'either' or 'Survivor' account )
    Pensioner's specimen signature :-
    1) _______________________________________________________________________________
    2) _______________________________________________________________________________
    3) _______________________________________________________________________________




    FORM - C
    ( To be submitted in duplicate )
    PART - I
    Rule 14( 1 ) (a)
    Form of Application for Commutation of Pension
    Without Medical Examination
    1. Name ( in Block Letters ) : ___________________________________
    2. Date of birth : ___________________________________
    3. Date of superannuation on attaining the age of 58 years ( or 60 years in the case of Group 'D' Employee ) : ___________________________________
    ___________________________________
    4. Designation of the post held at the time of superannuation and the name of the Department / Office. : ___________________________________
    ___________________________________
    5. Amount of pension sanctioned and whether it is provisional or final : ___________________________________
    6. Class of pension as defined in the West Bengal Services ( Death-Cum-Retirement Benefit ) Rules, 1971. : ___________________________________
    ___________________________________
    7. Name of treasury of Bank and Account Number from which pension is beingh drawn : ___________________________________
    8. Name of Treasury of Bank through which the commuted value is desired to be paid, if payment is not disired through the Accounts Officer who authorised the Pension. : ___________________________________
    ___________________________________
    9. Designation of the Accounts Officer and the Number and date of the Pension payment order, if issued. : ___________________________________
    ___________________________________
    10. Account ( in whole Rupees ) of Pension and portion of pension proposed to be commuted : ___________________________________
    ___________________________________
    11. Particulars of any application for commutation of pension made proviously and whether appeared before any Medical Authority or not. : ___________________________________
    __________________________________
    Date : ___________________________________
    Signature
      Full Address : ___________________________________
    ___________________________________
    ___________________________________


    PART - II


    Forwarded to the ____________________________________________________________________________________for
    ( Account Officer )
    authorised the payment of the commuted value. The receipt of Part - I of Form C has been acknowledged in Part - III which has been forwarded separately to the applicant on ______________________________________.

    Dated      :

    ( Signature of the competent Authority )



    PART - III
    Acknowledgement


    Received from Shri ____________________________________________________________________________________ retired ________________________________ an application for commutation of pension without medical examinatiion.

    Dated      :

    ( Signature of the competent Authority )



    NOTE : This acknoledgement is to be signed, stamped and dated and is to be detached from the Form and handed over to the applicant. If the form is received by post, it has to be acknowledged on the same day and sent under registered civer to the applicant.

    ANNEXURE - 1
    ( To be submitted in triplicate )

    Memo No.335-F (Pen) Dt. 07.03.2001


    PARTICULARS OF PENSIONER
    EMPLOYEE CODE :  
    NAME :  
    OFFICE NAME :  
    FATHER'S/HUSBAND'S NAME :  
    ADDRESS :  
    PENSION SANCTION AUTHORITY : Kolkata Pay & Account Office - II


    EMOLUMENTS FOR PENSION
    A. PAY SCALE :  
    B. LAST PAY :  
    C. SPECIAL PAY : NIL
    D. N.P.P. : NIL
    E. ADDITIONAL PAY : NIL
    F. P.H.PAY : NIL
    G. DEARNESS PAY : NIL
    H. OTHER ELEMENTS : NIL

    AMOUNT RECKONABLE FOR PENSION Rs.
    EMOLUMENT FOR GRATUITY : Rs.
    A. DEARNESS ALLOWANCE : Rs.
    AMOUNT RECKONABLE FOR GRATUITY Rs.

    Checked and verified

    Section Officer
    Finance Department, Checking Section.



    ANNEXURE - 1
    ( To be submitted in triplicate )

    Memo No.335-F (Pen) Dt. 07.03.2001

    Date of Birth
    Date of Ending of Service    		 :
    i) On Retirement :   (A/N)  
    ii) On Death : N/A    
    Date of Entry into Service :  
    Length of Service
    A. Gross Service (YY-MM-DD) : YEAR MONTH DAYS
    B. Weight age (YY-MM-DD) : NO    
    C. Less non-qualifying period of service (if any) : NIL    
      i) E.O.L. on private ground : NIL    
      ii) Period of Break if condoned :  
    Net length of Service : YEARS MONTHS DAYS
    Qualifying Service (6 monthly period) :
    Class of Pension : SUPERANNUATION
    Pension Disbursing Authority :  
    Salary Disbursing Authority i.e. Name of treasury or respective PAO, Kol. : Kolkata Pay & Account Office - II
    Age on next Birthday : 60 years
    Pension amount applied for commutation : 40% of Basic Pension
    Over drawal of pay and/or advance to be recovered against gratuity : NIL
    Outstanding dues as per pay certificate issued by Head of Office/DDO : NIL
    P.P.O./G.P.O. Number
    ( To be filled in by Finance deptt. )    		 :  

    Details of Family Pension/Gratuity/LTA Pension Nominee.
      Family Pension Block  
    NAME RELATION DATE OF BIRTH


    ANNEXURE - 1
    ( To be submitted in tripliocate )

    Memo No.335-F (Pen) Dt. 07.03.2001

    GRATUITY BLOCK
    NAME RELATION DATE OF BIRTH
    LIFE TIME ARREAR PENSION BLOCK
    NAME RELATION DATE OF BIRTH


    Amount of Pension :  
    date of Commencement :  
    Amount of Pension Commuted : 40% of Rs.
    Reduced Pension Payable : Rs.
    Commuted Value of Pension : Rs.
    Date of Restoration of CPP : As per existing rule.
    Amount of Retiring Gratuity :  
    Death Gratuity ( if Payable, Family Pension at enhance rate :  
    Duration of EFP - From : The date of death of Sri.
    Upto :  
    Family Pension at normal rate :  
    Duration of NFP - From :  
    Upto : Death of wife of Sri.


    Signature of Head of Office
    (With Official Seal)

    Checked & Verified
    Section Officer, Finance Department
    Zone No.

    Counter Signature

    Assistant Secretary/Dy. Secretary to the Govt. of
    West Bengal, Finance Department.



    ANNEXURE - II


    FORM OF APPLICATION ( Family Pension Scheme, 1965 ) Application for a family pension for the family of late __________________
    ( Designation )


    In the Office/Department of .............................................................
    1. Name of the Applicant :-  
    2. Relationship to the deceased Government Servent/Pensioner. :-  
    3. Date of retirement, if the deceased was a pensioner :-  
    4. Date of death of the Govt. Servant / Pensioner. :-  
      Widow/Widower Name Date of Birth
    (by Christian era)
      Sons    
      Unmarried Daughters    
      Parents    
    6. Name of Treasury/Sub-Treasury at which payment is desired. :-  
    7. Signature of left-hand-thumb impression ( in the case of house who are not literate enough to sigh their name ). :-  

    8. Descriptive roll of ________________________________________________________________________________________ Widow/Widower/Guardian of the minor children/parents of Late _______________________________________________________

    i) Date of birth ( Christian era )
    ii) Height
    iii) Personal marks, if any, on hand or face.
    iv) Left hand thumb and finger impression.
    Small Finger Ring Finger Middle Finger Index Finger Thumb




    Attested by :-
      i) .........................................................................................
      ii).........................................................................................

    Note :- The descriptive Roll (Column 8) and Signature or Left - hand thumb and finger impression accompanying application for family pension should be in duplicate ( in two separate sheets and attested by two gazetted officers or persons of respectability in the town, village or pargana in which the applicant resides).



    ANNEXURE - III

    FORM SANCTIONING FAMILY PENSION
    1. Name of the Government servant :  
    2. Father's Name :  
    3. Religion and Nationality :  
    4. Last appointment including Name of Establishment :  
    5. Date of begining of service :  
    6. Date of ending of service :  
    7. Substantive apointment held :  
    8. Pension rules, eligible :  
    9. Length of continuos qualifying service prior to death :  
    10. Pay as per Pare 2 of the Finance Deptt.
    Memo No.3944-F, dated 20.09.1965    		 :  
    11. Amount of family pension admissible :  
    12. Date from which pension is to commence :  
    13. Place of payment ( Government Treasury or sub-Treasury ) :  


    The undersigned having satisfied himself of the above particulars of Late _____________________ formerly ______________________________________ hereby orders the grant of a family pension of Rs. _______________________ (Rupees __________________________________________________________) per month for the period from ________________________________ to ____________________________ and thereafter @ Rs. __________________________ ( Rupees _______________________________________________ ) per month from ______________________________ to Shri / Smt. ___________________________________________ wife / husband __________________________________ of Late ________________________________________ till his / her death or re-marriage whichever is earlier as reported by the Audit Officer under the rules.

    Signature and Designation of
    Sanctioning Authority
    Memo No.____________________ Kolkata, the ______________________________
    copy forwarded to the Accountant General, West Bengal, Treasury Buildings, Kolkata - 1, for information with reference to audit report No.____________________________
    Dated ______________________.  
       
       
    Head of Office / Pension
    Sanctioning Authority
       
       
    No._____________________ Kolkata, the _______________________
       
    Copy along with the above endorsements, forwarded to -


    1.
    2.

    Head of Office / Pension
    Sanctioning Authority



    Specimen Signature of Shri / Smt. ............................................................. of KOLKATA PAY & ACCOUNT OFFICE - II, P-1, HYDE LANE, KOLKATA - 700073.
      1) ______________________________________________________________________
      2) ______________________________________________________________________
      3) ______________________________________________________________________


    Specimen Signature of Shri / Smt. ............................................................ of KOLKATA PAY & ACCOUNT OFFICE - II, P-1, HYDE LANE, KOLKATA - 700073.
      1) ______________________________________________________________________
      2) ______________________________________________________________________
      3) ______________________________________________________________________


    Statement of family members of Shri / Smt ................................................... of Kolkata Pay & Account Office - II, P-I, Hyde Lane, Kolkata - 700073.
    Sl. No. Name Relationship with the Officer Date of birth Remarks







    Signature of the Officer
    Date :





    ANNEXURE - I
    FORM OF FAMILY PENSION
    NO. ..................................................
    GOVERNMENT OF WEST BENGAL
    Deapartment .........................................

    Dated, the .............................



    Subject :- Payment of pension in respect of Late Shri / Smt. ________________________

    ________________________________________________________________________________
    The undersigned has learnt with regret the death of Shri / Smt. ________________________________________________________, a________________________________________________________________________________
    (Designation)

    in this Office / Department and is directed to inform you that under provisions of rule 104 of West Bengal Service (Death-cum-Retirement Benefit) Rules 1971 you are entitled of family pension for life / till ataining the date of majority.*

    I am accordingly to suggest that formal claim of the grant of family pension may be submitted by you in the enclosed Form along with the following documents namely :-
      1) death certificates,
      2) two copies of passport size photograph duly attested by a gazetted officer.
      3) Guardianship certificate where pension is admissible to the minor children.

    (Designation)



    To
    _______________________________________
    _______________________________________
    _______________________________________
    _______________________________________

    * Where family pension is admissible to the minor children.

    KOLKATA SHEET


    calculation sheet of SUPERANNUATION PENSION , RETIRING GRATUITY and FAMILY PENSION in respect of Sri / Smt. ____________________________________________________________ of KOLKATA PAY & ACCOUNTS OFFICE - II who is due to retire on Superannuation on _____________________________________________


    • Date of Birth
    		 :
      • Date of Appointment in Govt. Service.
      		 :
        • Date of Retirement on Superannuation
        		 :
          • Length of Qualifying Service.
          		 :
            • Emoluments to be drawn as per G.O. N. 7306 - F, dated 16.10.1998
            		 :
              • Superannuation Pension as per G.O. as above read with G.O. No.      1127-F (Pen) dated 27.10.1998
              		 :
                • Amount of Commutation of Pension
                		 :
                  • Value of Commutation portion of Pension
                        ( @ Rs. 117.72 per rupee 1 )
                  		 :
                    • Pension after Commutation.
                    		 :
                      • Monthly Family Pension as per G.O. as above.
                      		 :
                        • Retiring Gratuity as per G.O. as above
                        		 :




                        In the event of death of Sri/Smt. ________________________________________________________ his/her ____________________________ Sri/Smt. ___________________________________ will be entitled to get Family Pension at the enhance rate of Rs. _______________________________ upto ____________________ from the date following death of her / his husband / wife and therafter Rs. ______________________________ with effect from ____________________________ till her/his death or remarriage whichever is earlier.

                        Date of commencement of pension :

                        Pay & Accounts Officer
                        Kolkata Pay & Accounts Office - II