FORM OF NOMINATION
Account No. :. . . . . . . . . . . . . .
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby nominate the person (s) mentioned below who is/are member(s)/non-
members of my family defined in rule 2 of the General Provident Fund (Central Service) Rules, 1960, to received the amount that may stand any credit in the Fund as
indicated below, in the event of my death before that amount has become payable or having become payable has not been paid.
Name and full address of the nominee (s) Relationship Age of the Share Contingencies Name, address and If the nominee
with the nominee payable on the relationship of the is not a member
subscriber (s) to each happening of persons(s) if any to whom of the family as
nominee which the the right of nominee shall provided in rule
nomination will pass in the event of his/her 2, indicate the
become invalid predeceasing the subscriber reason
1 2 3 4 5 6 7
P.T.O
Page : 2
Dated this . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . 20 at . . . . . . . . . . . . . . . . . . . . . . . .
Signature of the subscriber :
Name in BLOCK letters :
Designation
Two witnesses to signature
Name and Address Signature
1.
2.
Space for use by the Head of Office/Pay and Accounts Office (reverse of the form)
Nomination by Shir/Smt./Kumari :
Designation : Signature of Head of Office/Pay and Accounts Officer
Date of receipt of nomination : Designation :
Date :
STATEMENT OF PARTICULARS FOR ALLOTMENT OF PROVIDENT FUND ACCOUNT NUMBERS TO
COMPULSORY SUBSCRIBERS FOR THE MONTH OF . . . . . . . . . . . . . . . . . . .
Office of the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (See Decision No.(3) below Rule 4)
Head of Account to which pay and allowances are debited . . . . . . . . . . . . . . . . . . . Please read carefully the instructions printed on the reverse before filling in the form
Sl. Name of Govt. Name of Subscriber's Date of Date of Designation Emolu- Monthly rate Month from Remarks to be filled in
No. Servant (subscriber) father/husband Birth of joining ments of which by Accountant
subscriber service subscription subscription General's Office
(in whole to Remarks Account
rupees) commence No.
allotted
1 2 3 4 5 6 7 8 9 10 11
No. Dated No. Dated
Forwarded in duplicate to the Accountant General for necessary action. The Returned to . . . . . . . . . . . . . . . . . . . . Account Nos. allotted may be
Government Servants those names are included in their statements are required to join intimated to the subscribers and also noted in the Service Books, nominations and
the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fund under the other official records. In all correspondence connected with Provident Fund of
. . . . . . . . . . . . . . . . . . . . . . . . . . . rules of Government of . . . . . . . . . . . . . . . . . . . . . . . any subscriber, the account Number should be quoted. Receipt of nominations at
Their names have not been included in the previous statements and they are not Sl.Nos. thereby acknowledged.
already members of any Provident fund (nominations are enclosed as mentioned in
the remarks column)
Certified that all the employees whose names are shown above are eligible to
subscribed to the Provident Fund in accordance with the relevant Rules.
Accounts Officer :
Head of Office Office of the Accountant General . . . . . . . . . . . . . . . . . . . . . . . . . .
(Reverse of the form)
Instructions for filling the statement :-
(a) This form should be used only in cases where subscription to the Fund is compulsory.
(b) Separate forms should be used for different provident fund e.g. General Provident Fund, Contributory Provident Fund, etc.
(c) Separate form should be used for persons whose pay and allowances are debited to different major and sub-major heads of account.
(d) Name of the Fund may be filled in by suitable words (e.g) General Provident Fund (Central), Contributory Provident Fund (India), etc.
(e) The statements should be sent in duplicate. It should include permanent Government Servants who joined service in the previous month and are required to join the fund
compulsorily on entry into Government Service and temporary Government Servants who will complete one year's continuous service or otherwise become eligible to
subscribe to the Provident Fund, three months hence.
(f) COLUMN - 3 : - Husband's name (instead of father's name) may be given in respect of married female subscribers indicating the position.
(g) COLUMN - 7 :- Dearness pay, if any, may be distinctly shown.
(h) COLUMN - 8 :- Please see Rule of G.P. Fund (Central Services) Rules, 1960/ Contributory Provident Fund (India) Rules.
(i) COLUMN - 9 :- Under the G.P.Fund (Central Services) Rules, 1960, a temporary Government servant who complete one year's continuous service during the middle of
among shall commence subscribing to the G.P. Fund from his/her salary for the month following that in which he/she completes one year's service.
(j) The nomination should be obtained in the prescribed form from the subscriber and forward to the Accountant General along with this statement making a suitable note in
the remarks column.
FORM - 3
(See Rule 54 (12))
DETAILS OF FAMILY
1. Name of the Government Servant :
2. Designation :
3. Date of Birth :
4. Date of appointment :
5. Details of the members of my family* as on :
Sl. Name of the Members of Date of birth Relationship Initials of the Remarks
No. family* with the officer Head of Office
I hereby undertake to keep the above particulars upto date by notifying to the Head of Office
any addition or alteration.
Place :
Dated : Signature of the Employee.
* Family for this purpose means :-
1. Wife, in the case of a male Government Servant
2. Husband, in the case of a female Government Servant
3. Sons below 18 years of age and unmarried daughters below 21 years of age, including such son or
daughter adopted legally before retirement.
NOTE : Wife and Husband shall include respectively judicially separated wife and husband.
DECLARATION OF ALLEGIANCE TO THE CONSTITUTION OF
INDIA
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S/O . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
employed as a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
in the Office of the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
do hereby solemnly declare that I shall ever be loyal to the Constitution of India
Place : Signature :
Date : Name :
Designation :
OATH OF SECRECY
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S/O . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
employed as a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
in the Office of the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pondicherry do hereby solemnly declare that I have read the official secrecy Act and Central Civil
(Conduct) Rules and that I shall do nothing deregatory to the secrecy of Government Service.
Place : Signature :
Date : Name :
Designation :
DECLARATION OF HOME TOWN
I declared that my home town is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
village in the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . District in the . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . State.
Place : Signature :
Date : Name :
Designation :
FORM - 8
Nomination for benefits under the Union Territory Government Employees Group Insurance Scheme,
1984
*****
When the Government Servant has a family and wishes to nominate one number of or more than one
member thereof.
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby nominate the
person(s) mentioned below, who is/are members of my family, and confer on, him/them the right to
receive to the extend specified below any amount that may be sanctioned by the Union Territory
Government/Administration under the Union Territory Government Employees Group Insurance
Scheme, 1984 in the event of my death while in the service or which having become payable on my
attaining the age of superannuation may remain unpaid at my death.
Name and Relation- Age Share to be Contingencies on Name, address and
addresses of ship with paid * the happening of relation-ship of the
nominee/ Govt. which the person, if any to
nominees Servant. nomination shall who, the right of
become invalid the nomination
shall pass in the
event of
predeceasing the
Govt. Servant
1. 2. 3. 4. 5. 6.
N.B. The Government servant draw line across the blank space below, his last entry to prevent
insertion of any name after he has assigned.
Dated this day of 20 at
Signature of two witnesses
1.
2.
Signature of Govt. Servant
__________________________________________________________________________________
* This column should be filled in as to cover the whole amount that may be payable under the
insurance scheme.
NOMINATION FOR RETIREMENT GRATUITY/DEATH GRATUITY
(See Rule 53 (1))
When the Govt. Servant has a family and wishes to nominate one member, or more than one member,
thereof.
I, hereby nominate the person/persons
mentioned below who is/are members of my family, and confer on him/her/them the right to receive to
the extent specified below, any gratuity the payment of which may be authorised by the Central Govt.
in the event of my death while in service and the right to receive on my death, to the extent specified
below, any gratuity which having on become admissible to me on retirement may remain unpaid at my
death.
Original nominee(s) Alternate nominee(s)
Name and address of Relation- Age Amount Name, address, relationship & Amount
nominee/ nominees ship with of share Age of the person or persons, of share
the Govt. of if any, to whom the right of
Servant gratuity conferred on the nominee shall gratuity
payable pass in the event of the payable
to each nominee predeceasing the to each.
Govt. Servant but before the
receiving payment of gratuity.
1. 2. 3. 4. 5. 6.
This nomination supersedes the nomination made by me earlier on which stands cancelled.
NOTE: 1. The Govt. Servant shall draw lines across the blank space below the last entry to prevent the
insertion of any name after he has assigned.
2. Strike out which is not applicable.
Dated this day of 20 at
Signature of two witnesses
1.
2.
Signature of Govt. Servant
(TO BE FILLED IN BY HEAD OF OFFICE)
Nomination by :
Designation : Signature of Head of Office
Office : Designation :
Date :
ANNEXURE - II
Thiru /Tmt./Selvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i) That I am a bachelor/widower
ii) That I am married and have only one spouse living that I am married to a persons who has no
other spouse living.
iii) That I am married and have more than one spouse living that I am married to a person who
has more than one spouse living.
I request that in view of the reasons stated below : -
I may be granted exemption from the operation of restriction on the recruitment to service of persons
having more than one spouse living or having married to a persons having more than one spouse living.
I solemnly affirm that the above declaration is true and I understand that in the event of the
declaration being found to be incorrect after my appointment, I shall be liable to be dismissed from
service.
Reasons :
Place :
Date : Signature of Govt. Servant
NOTE : Please delete clauses not applicable.
