FIRST SCHEDULES
[ Rule 5 ( 3 ) ]
FORM OF GPF NOMINATION
I,___________________________________________hereby nominate the person(s) mentioned below who is / are member (s)/non-member(s) of my
family as defined in Rule 2 of the General Provident Fund (Central Services) Rules, 1960, to receive the amount that may stand to my 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 paid.
Name and full address of Relationship Age of the Share Contingencies on the Name, address and In the nominee is
the nominee(s) with the nominee(s) payable to happening of which the relationship of the not a member of the
Subscriber each nomination will become person(s) if any to whom family as provided
nominee invalid the right of nominee shall in Rule 2 indicate
pass in the event of his/her the reasons.
predeceasing the
subscriber
1 2 3 4 5 6 7
Dated this ___________________________day of 20_________at _____________
Two Witnesses to Signature
Signature of the Applicant
1. Name and Address __________________________Signature___________________________ Name___________________________
Designation______________________
1. Name and Address __________________________Signature___________________________ Section / Branch__________________
Space for use by the Head of Office / Pay and Accounts Office
Nomination by Shri/Smt./Kumari_______________________________________ Designation__________________________________
Date of receipt of nomination__________________________________________ Signature of Head of Office / Pay and Accounts Office
Designation____________________________________
Date__________________________________________
Instructions for the subscriber:-
(a) Your name may be filled in.
(b) Name of the fund may be completed suitably.
©1 Definition of term “family” as given in the General Provident Fund (Central Services) Rules, 1960, is reproduced below:-
Family means:-
(i) in the case of a male subscriber, the wife or wives, parents, children, minor brothers, unmarried sisters, deceased son’s widow and children and
where no parent of the subscriber is alive a paternal grandparent.
Provided that if a subscriber proves that his wife has been judicially separated from him or has ceased under the customary law of the
community to which she belongs to be entitled to maintenance she shall henceforth be deemed to be no longer a member of the subscriber’s
family in maters to which these rules relate unless the subscriber subsequently intimates in writing to the Accounts Officer that she shall
continue to be so regarded.
(ii) In the case of a female subscriber, the husband, parents, children, minor brothers, unmarried sisters, deceased son’s widow and children and
where no parent of the subscriber is alive a paternal grandparent.
Provided that if a subscriber by notice in writing to the Accounts Officer expresses her desires to exclude her husband from her
family, the husband shall henceforth be deemed to be no longer a member of the subscriber’s family in matters to which these rules relate
unless the subscriber subsequently cancels such notice in writing.
Note:- Child means legitimate child and includes an adopted child where adoption is recognized by the personal law governing the subscriber or a ward under
the Guardians and Wards Act, 1890 (8 of 1890) who lives with the Government servant and is treated as a member of the family and to whom the Government
Servant has, through a special will, given the same status as that of a natural born child.
(d) Col.4. If only one person is nominated, the words “in full” should be written against the nominee. If more than one person is nominated, the share
payable to each nominee over the whole amount of the Provident Fund shall be specified.
(e) Col5. Death of nominee(s) should not be mentioned as contingency in this column.
(f) Col.6. Do not mention your name.
(g) Draw line across the blank space below last entry to prevent insertion of any name after you have signed.
Note2 – Deleted..
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1. & 2. Substituated /Deleted vide G.I.,Dept. of pen. & P.W., Notification No.20(6)-pen. & P.W. / 86, dated the 6th Februrary, 1987.
Form No 3
Details of Family
[ See Rule 54 (12) of CCS (Pension) Rules, 1972 ]
Name of the Government Servant :
Designation :
Date of Birth :
Date of Appointment :
Details of the members of my family *as on______________
S. Name of the Date of Relationship with Initials of Remarks
No members of family* Birth the officer the Head
of Office
1 2 3 4 5 6
1
2
3
4
5
6
7
8
9
10
I hereby undertake to keep the above particulars up to date by notifying to
the Head of office any addition or alteration.
Place__________ Signature of the Government Servant.
Dated the__________
*Family for this purpose means family as defined in clause (b) of sub-rule
(14) of Rule 54 of the CCS (Pension) Rules, 1972.
Note:- Wife and husband shall include respectively judicially separated wife
and husband.
Form No 2
Nomination for Retirement Gratuity / Death Gratuity
[ See Rule 53 (1) of CCS (Pension) Rules, 1972 ]
When the Government servant has a family and wishes to nominate one member, or more
than one member, thereof.
I,___________________________________________hereby nominate the person/person(s) mentioned
below who is / are member(s) of my family and confer on him/them the right to receive, to the extent specified
below, any gratuity the payment of which may be authorized by the Central Government in the event of my death
while in service and the right to receive on my death, to the extent specified below, which having become admissible
to me on retirement may remain unpaid at my death:--
Original Nominee(s) Alternate Nominee(s)
This nomination supersedes the nomination made by me earlier on______________which stands cancelled.
Dated this ___________________________day of 20_________at _____________
Two Witnesses to Signature
1. Name _____________________Signature_______________
2. Name _____________________Signature_______________ Signature of Government Servant
(To be filled by the Head of Office)
Nomination by _______________________________ Signature of Head of Office
Designation__________________________________ Date_______________________
Date of receipt of nomination____________________ Designation__________________
___________________________________________________________________________________
* This column should be filled in so as to cover the whole amount of the gratuity.
** The amount/Share of the gratuity shown in this column should cover the whole amount / share
payable to the original nominee(s).
Form No 3
Nomination for Retirement Gratuity / Death Gratuity
[ See Rule 53 (1) of CCS (Pension) Rules, 1972 ]
When the Government servant has no family and wishes to nominate one member, or
more than one member, thereof.
I,___________________________________________hereby nominate the person/person(s) mentioned
below who is / are member(s) of my family and confer on him/them the right to receive, to the extent specified
below, any gratuity the payment of which may be authorized by the Central Government in the event of my death
while in service and the right to receive on my death, to the extent specified below, which having become admissible
to me on retirement may remain unpaid at my death:--
Original Nominee(s) Alternate Nominee(s)
This nomination supersedes the nomination made by me earlier on______________which stands cancelled.
Dated this ___________________________day of 20_________at _____________
Two Witnesses to Signature
1. Name _____________________Signature_______________
2. Name _____________________Signature_______________ Signature of Government Servant
(To be filled by the Head of Office)
Nomination by _______________________________ Signature of Head of Office
Designation__________________________________ Date_______________________
Date of receipt of nomination____________________ Designation__________________
___________________________________________________________________________________
* This column should be filled in so as to cover the whole amount of the gratuity.
** The amount/Share of the gratuity shown in this column should cover the whole amount / share
payable to the original nominee(s).
Form No 7
[ See Para 19.5 ]
Nomination for benefits under the
Union Territory Government Employees Group Insurance Scheme, 1984
When the Government servant has no family and wishes to nominate one person or more
than one person.
I,____________________________________having no family, hereby nominate the person/person(s)
mentioned below and confer on him/them the right to receive to the extent specified below any amount that may be
sanctioned by the Union Territory Government under the Union Territory Government Employees
Group Insurance Scheme, 1984, in the event of my death while in service or which having become payable
on my attaining the age of superannuation may remain unpaid at my death.
! "
"
Dated this ___________________________day of 20_________at _____________
Two Witnesses to Signature
1. Name _____________________Signature_______________
2. Name _____________________Signature_______________ Signature of Government Servant
Nomination by _______________________________ Signature of Head of Office
Designation__________________________________ Date_______________________
Date of receipt of nomination____________________ Designation__________________
___________________________________________________________________________________
N.B. --- The Government servant should draw line across the blank space below his last entry to prevent the
insertion of any names after he has signed.
* This column should be filled in so as to cover the whole amount that may be payable under the Insurance scheme.
** Where a Government servant who has no family makes a nomination, he shall specify in this column that the
nomination shall become invalid in the event of his subsequently acquiring a family.
Form No 8
[ See Para 18 & 19.5 ]
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 member or more
than one member thereof.
I,____________________________________ hereby nominate the person/person(s) mentioned below who
is / are member(s) of my family and confer on him/them the right to receive, to the extent specified below any
amount that may be sanctioned by the Union Territory Government under the Union Territory Government
Employees Group Insurance Scheme, 1984, in the event of my death while in service or which having
become payable on my attaining the age of superannuation may remain unpaid at my death.
! "
"
Dated this ___________________________day of 20_________at _____________
Two Witnesses to Signature
1. Name _____________________Signature_______________
2. Name _____________________Signature_______________ Signature of Government Servant
Nomination by _______________________________ Signature of Head of Office
Designation__________________________________ Date_______________________
Date of receipt of nomination____________________ Designation__________________
___________________________________________________________________________________
N.B. --- The Government servant should draw line across the blank space below his last entry to prevent the
insertion of any names after he has signed.
* This column should be filled in so as to cover the whole amount that may be payable under the Insurance scheme.
Form No 4
Nomination for Arrears of Pension
[ See Rule 5 (1) of the Payment of Arrears of Pension (Nomination) Rules, 1983 ]
Pension Disbursing Authority / Head of Office
(Name of Bank / Treasury / Post Office / Accounts Officer, etc)
Place________________________
I,___________________________________________hereby nominate the person named below under Rule 5 of the Payment of Arrears of Pension
(Nomination) Rules, 1983.
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1 2 3 4 5 6 7 8 9
Place:_______________ Signature (or thumb-impression if illiterate)________________________
Date :_______________ Name of the Pensioner__________________________________________
Address______________________________________________________
Witness : Signature :___________________
Name & Address ______________________________
Signature of Pension Disbursing Authority / Head of Office
Acknowledgement to be sent by the Pension Disbursing Authority / Head of Office
Certified that application / nomination has been received from___________________________________whose address is_______________________________
_____________________________________________________
Place____________________________________ Signature of Pension Disbursing Authority________________________
Date____________________________________ Bank/ Treasury / Post Office / Accounts Officer____________________
Head of Office________________________________________________
Full Address__________________________________________________
Form No 5
( Revised ) Nomination for Arrears of Pension
[ See Rule 5 (5) of the Payment of Arrears of Pension (Nomination) Rules, 1983 ]
Pension Disbursing Authority / Head of Office
(Name of Bank / Treasury / Post Office / Accounts Officer, etc)
Place________________________
I,___________________________________________hereby make the following alternate nomination in cancellation of the previous nomination made
on ______________________under Rule 5 of the Payment of Arrears of Pension (Nomination) Rules, 1983.
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1 2 3 4 5 6 7 8 9
Place:_______________ Signature (or thumb-impression if illiterate)________________________
Date :_______________ Name of the Pensioner__________________________________________
Address______________________________________________________
Witness : Signature :______________________
Name & Address ______________________________ Signature of Pension Disbursing Authority ________________________
Date Stamp :
Certified that application / nomination (Form B )has been received from___________________________________whose address is_______________________
____________________________Form ‘A’ has been cancelled and returned to him.
Place____________________________________ Signature of Pension Disbursing Authority________________________
Date____________________________________ Bank/ Treasury / Post Office / Accounts Officer____________________
Full Address__________________________________________________
Form No 12
Nomination for Payment of Commuted Value of Pension
[ See Rule 7 of CCS (Commutation of Pension) Rules, 1981 ]
To
_________________________Head of Office
(Place)________________________
I,___________________________________________hereby nominate the person named below under Rule 7 of the Central Civil Services
(Commutation of Pension ) Rules, 1981.
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$
$
1 2 3 4 5 6 7 8 9
Place:_______________ Signature (or thumb-impression if illiterate)________________________
Date :_______________ Name of the Pensioner__________________________________________
Address______________________________________________________
Witness : Signature :___________________
Name & Address ______________________________ Signature of Head of Office
Stamp
Acknowledgement to be sent by Head of Office
Certified that nomination has been received from___________________________________whose address is_________________________________________
_____________________________________________________
Place____________________________________ Signature of Head of the Office__________________________________
Date____________________________________ Full Address__________________________________________________
FORM
HOME TOWN DECLARATION
[ OM No. 43/15/57-Estts. (A) dated 24-6-1958 ]
I, ___________________________hereby declare that my home town is at the
place as shown below for the purpose of availing my self of the Travel Concession
as notified in the Govt. of India, Ministry of Home Affairs, New Delhi O.M. No.
43/1/55/Estts - (A) Part-II dated 11-1-1956 conveyed vide Secretary (Finance) to the
Delhi Administration endorsement No. F 13(3) / 54 / Finance dated 22-12-1956.
Name of State Name of the Name of the Name of the Remarks
District Village Railway
station
1. 2. 3. 4. 5
Signature of the Govt. Servant
Nomination by _______________________________ Signature of Head of Office
Designation__________________________________ Date_______________________
Date of receipt of nomination____________________ Designation__________________
