NAME OF THE OFFICE………………………………………..

PENSION PAPERS
.

OF

SRI/SMTI………………………………………..

DATE OF RETIREMENT ……………………………..

ON
*Superannuation/*voluntary retirement/*absorption in autonomous body/*Invalid pension
* Please strike out which is inapplicable .

Compiled and Circulated by-

The Directorate of Audit and Pension,

Government of Audit and Pension,
Naharlagun .

1
 Form-8
( Form of letter to the Director of Audit and Pension forwarding the pension papers of a Government servant )

Department……………….
Office…………………..…
No…………… Dated……..

To

The Director of Audit and Pension,

Government of Arunachal Pradesh,
Naharlagun.

Sub:- Pension papers of Sri/Smti...................................................... for authorization of pension.

Sir,

I am to forward herewith the pension papers of Sri/Smti…. Of this office /Department form
further necessary action.
2.The details of Govt. dues which will remain outstanding on the date of retirement of the
Government servant and which need to be recovered out of the amount of the retirement gratuity are
indicated below-
(a) Balance of house-building or conveyance advance--------……………..….Rs.
(b) Overpayment of pay and allowances including leave salary…….……..….Rs.
© Income tax deductible at source under Income Tax Act 1961,
1961(43of 1961)……………………………………………………….…Rs.
(d) Arrears of license fee for occupation of Government accommodation…….Rs.
(e) The amount of license fee for retention of government accommodation
for the permissible period of two months beyond the date of retirement ….Rs.
(f) Any other assessed dues and the nature thereof………………………….....Rs.
(g) The amount of gratuity to be withheld for adjustment of unassisted
dues, if any…………………………………………………………………....Rs.___________
Total Rs.___________
3. Your attention is invited to the list of enclosures which is forwarded herewith.
4. The receipt of the letter may be acknowledged and this Department /Office informed that
necessary instruction for the disbursement of pension have been issued to disbursing authority concerned.
5. The retirement gratuity will be drawn and disbursed by the Department/office on receipt of the
authority from you. The outstanding Government dues as mentioned in the para 2 above will also be
recovered out of the retirement gratuity before making payment.

Yours faithfully

Head of office.

2
 List of enclosures-

1. Form-1 - Nomination for Death-cum-Retirement gratuity ,- See Rule,53 …..;….1 copy

2. Form 3 - Details of Family -See Rule 54(12), duly completed and signed
and authenticated by Head of Office……...........................................................1 copy
3. Form -5 Particulars , obtained by HoO from Govt. servant
-See Rule 59(1)© & 61(1), duly completed and signed by the Govt. Servant……...1 copy

4.Form- 7- Form for assessing pension and Gratuity- See Rule 58,60,61(1) &(3)
and 65, duly filled up and signed… …………………...………………… ….....2copies
5. Application for commutation of pension :-
Form-1 See Rule 5(2),6(1),12,13(1)and (2),14(1) and (2),15(1) and (2),16(1)and (2)
CCS(Commutation of Pension) Rules 1981.
or
Form -1 - A See Rule 5(2), 12,13(3),14(1)15(3), CCS(Commutation of Pension) Rules 1981….. ..1.copy

6. Pension calculation sheet……………………………………………….....…..…1 copy

7. Drawal statement of last 10 months…………………………………….………..1 copy

8. Last pay certificate(LPC)……….……………………….......................................1 copy
9. No Demand certificate from the HoO, as required under Rule 57,63 & 71)
and Audit /AC bill clearance certificate………………………………………….1 copy
10. Vigilance clearance certificate from Vigilance Department
of State Government …..………………………………………………………....1 copy
11. Loan clearance certificate( irrespective of whether loan taken or not)
issued by the Director of Accounts & Treasuries Govt. of Arunachal
Pradesh…………………………………………………………………………..1copy
12.Specimen signature/thumb impression(if illiterate)and Descriptive roll
indicating height & identification mark of the claimant duly attested
by the HoO……………………………………………………………………...2 copies
13. Medical certificate of incapacity (in case of invalid pension only)
in form 23 of CCS ( Pension ) Rules………………………………………..…...1 copy.
14. Passport size Photograph/Joint photograph of ( Husband and wife if both are alive)
duly attested by Head of office …….………………………………………..…. 3 copies
15. Service book duly verified with A/Roll and attested with following entries in –
a. Date of retirement/absorption in Autonomous Body
along-with copy of order.
b. Payment /Non payment of provisional gratuity and Pension
with copy of sanction order, if sanctioned.
c. Date of acceptance of voluntary retirement with copy of order.
d. Date of membership in the UTGEGIS, 1984.
e. Date of change of Group status with rate of subscription.
f. Enhanced rate of subscription from 1.1.1990.
g. Date of cessation from the membership.

*************//*****************

3
 FORM-1
(See Rule 53(I0of the CCS(Pension)Rules 1972)

Nomination for Death –cum Retirement Gratuity

When Government servant has 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 /them the right to receive, to the extent specified below,
any gratuity that may be sanctioned by the by Government in the event of my dea5th while in service and
the right to receive on my death ,to the extent specified below, any gratuity which having become
admissible to me on my retirement may remain unpaid at my death.
_________________________________________________________________________________
Original Nominee(s) Alternative Nominee(s)
Name and address of the Relationship with Age Amount of Name, address, relationship and age Amount or
nominee/nominees the Govt. servant. the share of the person or persons, if any, to share of
of gratuity whom the right conferred on the gratuity
payable to nominee shall pass in the event of the payable to
each. nominee predeceasing the Govt. each.
servant or the nominees dying after
the death of the Govt. servant but
before receiving the payment of the
gratuity.

This nomination supersedes the nomination made by me earlier on ……………. Which stands cancelled
Note:- (i) The Government servant shall draw lines across the blank space below the last entry
to prevent the insertion of any name after he has signed.
(ii) Strike out which is not applicable.
(iii) Dated this day……………………..day of ……………201…at ……..
Witness to sign:

1…………………………

2…………………………

Sig. of the Govt. Servant

(To be filled in by the Head of Office)

Nomination by ………………………. Sig.of Head of Office…………..

Designation ………………………… Date………………
Office………………………… Designation………

4
 FORM NO.3
DETAILS OF FAMILY MEMBERS
See Rule 54(12)

1. Name of the Government Servant :-

2. Designation :-
3. Date of appointment :-
4. Details of members of family as on____________

Sl.No. Name of the Date of Relationship Initials of the Remarks

members of birth& age with the Head of office
the family official

I hereby undertake to keep the above particulars up to addition by notifying the Head of office/Audit
officer any addition or alteration.

Place:
Date : Signature of the Govt. servant
_____________________________________________________________________
Family for this purpose means:
(a) Wife in case of the male Govt. servant.
(b) Husband in case of the female Govt. servant.
(c) Sons below 18 years of age ,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.

5
 FORM-5
See Rule 59 (1) (C) and 61 (1)

Particulars to be obtained by the Head of Office from the retiring Government servant eight months before the
date of retirement .

1. Name :-
2. (a) Date of birth :-
(b) Date of retirement :-
3. Two specimen signature to be furnished
In a separate sheet duly attested by a gazetted
Government servant :-
4. Three copies of passport size joint photograph
With wife or husband as the case may be duly
Attested by the Head of office. :-
5. Two slips showing the particulars of height and
Personnel identification marks duly attested by a
Gazzetted Government servant. :-
_________________________________________________________________________________

1. Two slips each bearing the left thumb finger impression

dully attested may be furnished by a person who is not
literate to sign the name. If such a Govt. servant on account
of physical disability is unable to give thumb and finger
impression of the right hand where the Government servant
has lost both the hands he may give his toe impression
should be duly attested by a gazetted Government servant.
2. Two copies of passport size photograph of self only needed.
(i) If the Government servant is Governed by Rule
54 of the CCS(Pension) Rules 1972 and is
unmarried or a widower or widow.
(ii) If Government servant is Governed by Rule
55 of CCS(Pension )Rules1972.
3. When it is not possible for a Government servant to submit
photograph with his wife or her husband he or a she may submit
separate photograph. The photographs shall be attested by the
Head of office.
4. Specify a few conspicuous marks not less than two if possible.
5. Present address:-
6. Address after retirement:-
7. Name of the treasury or Branch of Public Sector Bank or the
Pay and Accounts Officer through which Pension is to be
Drawn:-
8. Details of family in Form-3.
9. Indicate whether family pension is admissible from any other
Sources i.e. Military or State Government and or Public Sector
Undertaking /autonomous body Local Fund under the central or
State Government.

Place
Date Signature of Govt. Servant…………

Department/Office………….

6
 FORM – 7 (Revised)

FORM FOR ASSESSING PENSION /FAMILY PENSION AND GRATUITY

PART –I

1. Name of the retiring Government employee :-

2. Father’s/Husband’s Name :-
3. Height :-
4. Marks of identification :-
5. Date of birth :-
6. Service to which belongs (indicate name of :-
organized service, if any, otherwise say,
General Central Service).
7. Particulars of post held at the time of
retirement. :-
(a) Name of the office :-
(b) Post held :-
(c) Whether the appointment mentioned
above was under Government or
outside the Government on foreign :-
service terms.
8. Whether declared substantive in any post
under the Central Government. :-
9. Date of beginning of service :-
10. Date of ending of service :-
11. Cause of ending of service :-
(a) Voluntary retirement on being :-
declared surplus (Rule 29)
(b) Permanent absorption in public :-
sector undertaking /autonomous
body (Rule 37-A).
(c) Due to abolition of post (Rule 59) :-
(d) Superannuation (Rule 35) :-
(e) Invalidment on medical ground :-
(Rule 38).
(f) Voluntary/premature retirement at :-
the initiative of the Government
servant under Rule 48, 48 –A and
FR 56 (k).
(g) Premature retirement at the initiative :-
of the Government Rule 48 or
FR 56 (j)
(h) Compulsory retirement (Rule 40) :-
(i) Removal /dismissal from service :-
(Rule 24 and 41)
(j) Death. :-

7
12. In the case of compulsory retirement, the :-
orders of the competent authority whether
pension may be allowed at full rates or at
reduced rates and, in case of reduced rates,
the percentage at which it is to be allowed.
13. In case of removal /dismissal from service :-
whether orders of competent authority have
been obtained for grant of compassionate
allowance and if so, at what rate.
14. Particulars relating to military services, if any:-
(a) Period of military service :-
(b) Terminal benefits drawn /being :-
drawn for military service.
(c) Whether opted for counting of :-
military service towards civil
pension.
(d) If answer to (c) above is in the :-
affirmative, whether the terminal
benefits have been refunded.
(e) In case of ex-servicemen who are :-
eligible for family pension under
the Armed Forces Rules, whether
opted to retain family pension under
the Armed Forces Rules or to draw
family pension under the Civil Rules.
15. Particulars relating to service in autonomous :-
body, if any
(a) Particulars of service :-
Name of organization Post held Period
From To

(b) Whether the above service is to be :-

counted for pension.
(c) Whether the autonomous organization
has discharged its pensionary liability
to the Central Government. :-
16. Whether any departmental or judicial :-
proceedings are pending against the
retiring employees.
17. Qualifying service :-
(a) Details of omission, imperfection or :-
deficiencies in the Service Book
which have been ignored.
[ under Rule 59(1)(b)(iii)]

8
 (b) Period not counting as qualifying
service-
i) Boy service (2nd proviso to :-
Rule 13).
ii) Extraordinary leave not :-
counting as qualifying service
(Rule 21).
iii) Periods of suspension not :-
treated as qualifying service
(Rule 23).
iv) Interruptions in service :-
[Rule 27 (1) (b) and
Rule 28 (c) ]
v) Period of foreign service with:-
United Nations bodies for
which United Nations pension
has been availed.
vi) Any other period not treated :-
as qualifying service (give
details).
c. Additions to qualifying service :-
i) Military service (Rule 19) :-
ii) War service (Rule 20) :-
iii) weightage on voluntary :-
retirement on being declared
surplus (rule 29).
iv) Weightage under Rule 30 :-
v) Benefit of service in an :-
autonomous body (Rule 37).
vi) weightage under Rule 48-B :-
d. Net qualifying service :-
e. Qualifying service expressed in terms:-
of completed six monthly period(period
of three months and over is treated as
completed six monthly period).
18. Emoluments:-
(a) Emoluments drawn during 10 months:-
preceding retirement.
From To Rate of Pay Amount

(b) If the Officer was on foreign service :-

immediately preceding retirement, the
motional emoluments which he would
have drawn under Government but
for being on foreign service.

(c) Average emoluments reckoned for :-

pension.

9
 (d) Emoluments reckoned for retirement :-
gratuity/death gratuity.
(e) Emoluments reckoned for family :-
pension.
19. Date on which the retiring employee :-
submitted his application for pension in
Form – 5.
20. Complete and up-to-date details of the :-
family as given in Form – 3
Sl. Name of the members of Date of birth Relationship with the
No. family officer

21. Whether nomination made for death gratuity :-

retirement gratuity.
22. The date on which action initiated to :-
(a) Obtain the ‘No demand Certificate’ :-
from the Directorate of Estates as
provided in Rule 57.
(b) Assess the service and emoluments :-
qualifying for pension as provided
in Rule 59 and
(c) Assess the Government dues other :-
than the dues relating to the allotment
of Government accommodation as
provided in Rule 73 (1)

23. Details of Government dues recoverable out :-

of gratuity.
(a) License fee for Government :-
accommodation [See sub-rules (2),
(3) and (4) of Rule 72]
(b) Dues referred to in Rule 73 :-
24. (a) Proposed pension/Service gratuity :-
(b) Proposed dearness relief on pension :-
(as on the date of retirement)
(c) Date from which pension is to :-
commence.
25. Rate of Family Pension :-
(a) Enhanced rate :-
(b) Period for which family pension :-
will be payable at enhanced rate.
(c) Ordinary rate :-
(d) Date from which ordinary rate of :-
family pension will be payable
5
26. Amount of retirement gratuity/death gratuity :-
27. Commutation of pension :-
(a) Whether simultaneously applied for :-

10
 Commutation of pension with the
Pension application (applicable only
in the case of those who retire on
Superannuation pension).
(b) The portion of pension commuted :-
(c) Commuted value of pension :-
(d) Amount of residuary pension after :-
deducting commuted portion.
(e) Date from which reduced pension :-
is payables.
28. Name and address of Bank/Pension :-
Accounting office from where pension is to
Be drawn.
29. Head of Account to which pension and :-
gratuity are debitable.
30. Post-retirement address of the retire. :-

Signature of the Head of Office.

11
 Part-II

1. Date of receipt of pension papers by the :-

Account Officer from Head of Office.
2. Entitlements admitted :-
A. Length of Qualifying Service :-
B. Pension
(i) Class of Pension :-
(ii) Amount of monthly pension :-
(iii) Date of commencement :-
C. Commutation of Pension
(i) Commuted value of portion of :-
Pension commuted, if any
(ii) Residuary Pension after commutation. :-
(iii) Date from which reduced pension is payable :-
(iv) Date of restoration of commuted portion :-
of pension subject to the pensioner
continuing to live.
D. Retirement / Death Gratuity :-
(i) Total amount payable :-
(ii) Amount to be adjusted towards :-
Government dues.
(iii) Amount to be withheld for adjustment :-
of unassessed dues.
(iv) Net amount to be released immediately :-
E. Family Pension :-
(i) At enhanced rate :-
(ii) Period for which family pension at :-
enhanced rate is payable.
(iii) At normal rate :-
3. Head of Account to which the amount of pension, :-
retirement / death gratuity and family pension are
to be debited.
Director of Audit and Pension

12
 FORM – 7 (Revised)
FORM FOR ASSESSING PENSION /FAMILY PENSION AND GRATUITY
PART –I

1. Name of the retiring Government employee :-

2. Father’s/Husband’s Name :-
3. Height :-
4. Marks of identification :-
5. Date of birth :-
6. Service to which belongs (indicate name of :-
organized service, if any, otherwise say,
General Central Service).
7. Particulars of post held at the time of
retirement. :-
(a) Name of the office :-
(b) Post held :-
(c) Whether the appointment mentioned
above was under Government or
outside the Government on foreign :-
service terms.
8. Whether declared substantive in any post
under the Central Government. :-
9. Date of beginning of service :-
10. Date of ending of service :-
11. Cause of ending of service :-
(a) Voluntary retirement on being :-
declared surplus (Rule 29)
(b) Permanent absorption in public :-
sector undertaking /autonomous
body (Rule 37-A).
(c) Due to abolition of post (Rule 59) :-
(d) Superannuation (Rule 35) :-
(e) Invalidment on medical ground :-
(Rule 38).
(f) Voluntary/premature retirement at :-
the initiative of the Government
servant under Rule 48, 48 –A and
FR 56 (k).
(g) Premature retirement at the initiative :-
of the Government Rule 48 or
FR 56 (j)
(h) Compulsory retirement (Rule 40) :-
(i) Removal /dismissal from service :-
(Rule 24 and 41)
(j) Death. :-

13
12. In the case of compulsory retirement, the :-
orders of the competent authority whether
pension may be allowed at full rates or at
reduced rates and, in case of reduced rates,
the percentage at which it is to be allowed.
13. In case of removal /dismissal from service :-
whether orders of competent authority have
been obtained for grant of compassionate
allowance and if so, at what rate.
14. Particulars relating to military services, if any:-
(a) Period of military service :-
(b) Terminal benefits drawn /being :-
drawn for military service.
(c) Whether opted for counting of :-
military service towards civil
pension.
(d) If answer to (c) above is in the :-
affirmative, whether the terminal
benefits have been refunded.
(e) In case of ex-servicemen who are :-
eligible for family pension under
the Armed Forces Rules, whether
opted to retain family pension under
the Armed Forces Rules or to draw
family pension under the Civil Rules.
15. Particulars relating to service in autonomous :-
body, if any
(a) Particulars of service :-
Name of organization Post held Period
From To

(b) Whether the above service is to be :-

counted for pension.
(c) Whether the autonomous organization
has discharged its pensionary liability
to the Central Government. :-
16. Whether any departmental or judicial :-
proceedings are pending against the
retiring employees.
17. Qualifying service :-
(a) Details of omission, imperfection or :-
deficiencies in the Service Book
which have been ignored.
[ under Rule 59(1)(b)(iii)]

(b) Period not counting as qualifying

14
 service-
i) Boy service (2nd proviso to :-
Rule 13).
ii) Extraordinary leave not :-
counting as qualifying service
(Rule 21).
iii) Periods of suspension not :-
treated as qualifying service
(Rule 23).
iv) Interruptions in service :-
[Rule 27 (1) (b) and
Rule 28 (c) ]
v) Period of foreign service with:-
United Nations bodies for
which United Nations pension
has been availed.
vi) Any other period not treated :-
as qualifying service (give
details).

c. Additions to qualifying service :-

i) Military service (Rule 19) :-
ii) War service (Rule 20) :-
iii) weightage on voluntary :-
retirement on being declared
surplus (rule 29).
iv) Weightage under Rule 30 :-
v) Benefit of service in an :-
autonomous body (Rule 37).
vi) weightage under Rule 48-B :-
d. Net qualifying service :-
e. Qualifying service expressed in terms:-
of completed six monthly period(period
of three months and over is treated as
completed six monthly period).
18. Emoluments:-
(a) Emoluments drawn during 10 months:-
preceding retirement.
From To Rate of Pay Amount

(b) If the Officer was on foreign service :-

immediately preceding retirement, the
motional emoluments which he would
have drawn under Government but
for being on foreign service.

(c) Average emoluments reckoned for :-

pension.
(d) Emoluments reckoned for retirement :-

15
 gratuity/death gratuity.
(e) Emoluments reckoned for family :-
pension.
19. Date on which the retiring employee :-
submitted his application for pension in
Form – 5.
20. Complete and up-to-date details of the :-
family as given in Form – 3
Sl. Name of the members of Date of birth Relationship with the
No. family officer

21. Whether nomination made for death gratuity :-

retirement gratuity.
22. The date on which action initiated to :-
(a) Obtain the ‘No demand Certificate’ :-
from the Directorate of Estates as
provided in Rule 57.
(b) Assess the service and emoluments :-
qualifying for pension as provided
in Rule 59 and
(c) Assess the Government dues other :-
than the dues relating to the allotment
of Government accommodation as
provided in Rule 73 (1)

23. Details of Government dues recoverable out :-

of gratuity.
(a) License fee for Government :-
accommodation [See sub-rules (2),
(3) and (4) of Rule 72]
(b) Dues referred to in Rule 73 :-
24. (a) Proposed pension/Service gratuity :-
(b) Proposed dearness relief on pension :-
(as on the date of retirement)
(c) Date from which pension is to :-
commence.
25. Rate of Family Pension :-
(a) Enhanced rate :-
(b) Period for which family pension :-
will be payable at enhanced rate.
(c) Ordinary rate :-
(d) Date from which ordinary rate of :-
family pension will be payable

26. Amount of retirement gratuity/death gratuity :-

27. Commutation of pension :-
(a) Whether simultaneously applied for :-
Commutation of pension with the

16
 Pension application (applicable only
in the case of those who retire on
Superannuation pension).
(b) The portion of pension commuted :-
(c) Commuted value of pension :-
(d) Amount of residuary pension after :-
deducting commuted portion.
(e) Date from which reduced pension :-
is payables.
28. Name and address of Bank/Pension :-
Accounting office from where pension is to
Be drawn.
29. Head of Account to which pension and :-
gratuity are debitable.
30. Post-retirement address of the retire. :-

Signature of the Head of Office.

17
 Part-II

1. Date of receipt of pension papers by the :-

Account Officer from Head of Office.
2. Entitlements admitted :-
A. Length of Qualifying Service :-
B. Pension
(i) Class of Pension :-
(ii) Amount of monthly pension :-
(iii) Date of commencement :-
C. Commutation of Pension
(i) Commuted value of portion of :-
Pension commuted, if any
(ii) Residuary Pension after commutation. :-
(iii) Date from which reduced pension is payable :-
(iv) Date of restoration of commuted portion :-
of pension subject to the pensioner
continuing to live.
D. Retirement / Death Gratuity :-
(i) Total amount payable :-
(ii) Amount to be adjusted towards :-
Government dues.
(iii) Amount to be withheld for adjustment :-
of unassessed dues.
(iv) Net amount to be released immediately :-
E. Family Pension :-
(i) At enhanced rate :-
(ii) Period for which family pension at :-
enhanced rate is payable.
(iii) At normal rate :-
3. Head of Account to which the amount of pension, :-
retirement / death gratuity and family pension are
to be debited.
Director of Audit and Pension

18
 FORM-1
FORM OF APPLICATION FOR COMMUTATION OF FRACTION OF PENSION WITHOUT MEDICAL
EXAMINATION
See Rule 5(2),6(1),12,13(1)and (2),14(1) and (2),15(1) and (2),16(1)and (2) of CCS(Commutation of Pension)
Rules,1981.

(To be submitted in duplicate after retirement but within one year of the date of retirement )

PART-I
To

The Director of Audit and Pension

Government of Arunachal Pradesh
Naharlagun.

Sub:- Commutation of pension without medical examination.

Sir,
I desire to commute a fraction of pension indicated below in accordance with the provision
of CCS( Commutation ) Pension Rules 1981.The necessary particulars are furnished below:-

1. Name (in block letters) :-

2. Father’s name (husband’s name in the case of female Government servant ) :-

3. Designation at the time of retirement :-

4. Name of the office Department in which employed :-

5. Date of Birth in Christian era :-

6. Date of retirement :-

7. Class of pension on which retired :-

8. Amount of Pension authorized ,in case final amount of Pension has not been authorized,
indicate the amount of provisional Pension sanctioned under 1964 of the CCS (Pension) Rules
1972.

9. Fraction of pension proposed to be commuted :-

10. Designation of Accounts Officer who authorized

the Pension and the number and date of PPO :-

19
 PART-II

(ACKNOWLEDGEMENT)

Received from Sri/Smti/Kumari…………………………………..application in Part-I of Form-I

for commutation of pension without medical examination.

Place:-
Date:-
Signature of Head of Office

PART-III

Forwarded to the Director of Audit and Pension, Govt. of Arunachal Pradesh, Naharlagun with
the remarks that----

(i) The particulars furnished by the applicant inn part-I have been verified and and are correct.
(ii) The applicant is eligible to get pension commuted without medical examination.
(iii) The commuted value of pension determined with reference to the Table applicable at
present comes to Rs._________________________ and
(iv) The amount of residuary pension after commutation will be Rs._____________.

2. The pension papers of the applicant completed in all respect were forwarded under this
Office letter No.___________________________________dated_____________.It is
requested that
the payment of the amount of the commuted value of pension may be authorized through
PPO.
3. The receipt of the part-I of this form has been acknowledged in part –II which has been separately
forwarded to the applicant on _________________.

4. The commuted value of pension is debitable to H/A ___________.

Place:-
Date :-

Sig. Head of Office

20
 FORM-1
FORM OF APPLICATION FOR COMMUTATION OF FRACTION OF PENSION WITHOUT MEDICAL
EXAMINATION
See Rule 5(2),6(1),12,13(1)and (2),14(1) and (2),15(1) and (2),16(1)and (2) of CCS(Commutation of Pension)
Rules,1981.

(To be submitted in duplicate after retirement but within one year of the date of retirement )

PART-I
To

The Director of Audit and Pension

Government of Arunachal Pradesh
Naharlagun.

Sub:- Commutation of pension without medical examination.

Sir,

I desire to commute a fraction of pension indicated below in accordance with the provision
of CCS( Commutation ) Pension Rules 1981.The necessary particulars are furnished below:-

11. Name (in block letters) :-

12. Father’s name (husband’s name in the case of female Government servant ) :-

13. Designation at the time of retirement :-

14. Name of the office Department in which employed :-

15. Date of Birth in Christian era :-

16. Date of retirement :-

17. Class of pension on which retired :-

18. Amount of Pension authorized ,in case final amount of Pension has not been authorized,
indicate the amount of provisional Pension sanctioned under 1964 of the CCS (Pension) Rules
1972.

19. Fraction of pension proposed to be commuted :-

20. Designation of Accounts Officer who authorized

the Pension and the number and date of PPO :-

21
 PART-II

(ACKNOWLEDGEMENT)

Received from Sri/Smti/Kumari…………………………………..application in Part-I of Form-I

for commutation of pension without medical examination.

Place:-
Date:-
Signature of Head of Office

PART-III

Forwarded to the Director of Audit and Pension, Govt. of Arunachal Pradesh, Naharlagun, with
the remarks that---

(i)The particulars furnished by the applicant inn part-I have been verified and and are correct.
(ii)The applicant is eligible to get pension commuted without medical examination.
(iii)The commuted value of pension determined with reference to the Table applicable at present
comes to Rs._________________________ and
(iv)The amount of residuary pension after commutation will be Rs._____________.

2. The pension papers of the applicant completed in all respect were forwarded under this
Office letter No.___________________________________dated_____________.It is
requested that
the payment of the amount of the commuted value of pension may be authorized through
PPO.
3. The receipt of the part-I of this form has been acknowledged in part –II which has been separately
forwarded to the applicant on _________________.

4. The commuted value of pension is debitable to H/A ___________.

Place:-
Date :- Sig. Head of Office

22
 FORM-1-A

FORM OF APPLICATION FOR COMMUTATION OF FRACTION OF SPERANNUATION PENSION

WITHOUT MEDICAL EXAMINATION WHEN THE APPLICANT DESIRES THAT THE COMMUTED VALUE OF
PENSION SHOULD BE AUTHORISED THROUGH THE PENSION PAYMENT ORDER.
See Rule 5(2),12,13(3),14(1) and,15(3)of CCS (Commutation of Pension ) Rules, 1981.

(To be submitted in duplicate at least three months before the date of retirement)

PART-I
To

The Director of Audit and Pension

Government of Arunachal Pradesh
Naharlagun.

Sub:- Commutation of pension without medical examination.

Sir,
I desire to commute a fraction of pension indicated below in accordance with the provision
of CCS( Commutation ) Pension Rules 1981.The necessary particulars are furnished below:-
1. Name (in block letters) :-

2. Father’s name (husbands’ name in the case of female Government servant ) :-

3. Designation at the time of retirement :-

4. Name of the office Department in which employed :-

5. Date of Birth in Christian era :-

6. Date of retirement :-

7. Fraction of pension proposed to be commuted :-

8. Disbursing authority from which pension is to be drawn after retirement-
(a) Name and complete address of the Treasury/Sub-Treasury
(b) (i) Branch of the nominated Nationalized Bank
With complete postal address:-
(ii) Bank Account No. to which monthly
Pension is to be credited each month :-
© Accounts Office of the Ministry/Department/Office:-

Signature

Place:_ Present Postal address

Date:- ………………………………..
Postal address after retirement.
………………………………..

23
 PART-II

(ACKNOWLEDGEMENT)

Received from Sri/Smti/Kumari…………………………………..application in Part-I of Form I-A

for commutation of pension without medical examination.

Place:-
Date:-
Signature of Head of Office

PART-III

Forwarded to the Director of Audit and Pension, Govt. of Arunachal Pradesh, Naharlagun with
the remarks that ------

(i) The particulars furnished by the applicant inn part-I have been verified and and are correct.
(ii) The applicant is eligible to get pension commuted without medical examination.
(iii) The commuted value of pension determined with reference to the Table applicable at present
comes to Rs.________ ; and
(iv)The amount of residuary pension after commutation will be Rs._____________.

2. The pension papers of the applicant completed in all respect were forwarded under this Office
letter No.___________________________________dated_____________.It is requested that the
payment of the amount of the commuted value of pension may be authorized through PPO.
3. The receipt of the part-I of this form has been acknowledged in part –II which has been
separately forwarded to the applicant on _________________.

4. The commuted value of pension is debitable to H/A ___________.

Place:-
Date :-

Sig. Head of Office

24
 FORM-1-A

FORM OF APPLICATION FOR COMMUTATION OF FRACTION OF SPERANNUATION PENSION

WITHOUT MEDICAL EXAMINATION WHEN THE APPLICANT DESIRES THAT THE COMMUTED VALUE OF
PENSION SHOULD BE AUTHORISED THROUGH THE PENSION PAYMENT ORDER.
See Rule 5(2),12,13(3),14(1) and,15(3)of CCS (Commutation of Pension ) Rules, 1981.

(To be submitted in duplicate at least three months before the date of retirement)

PART-I
To

The Director of Audit and Pension

Government of Arunachal Pradesh
Naharlagun.

Sub:- Commutation of pension without medical examination.

Sir,
I desire to commute a fraction of pension indicated below in accordance with the provision
of CCS( Commutation ) Pension Rules 1981.The necessary particulars are furnished below:-
9. Name (in block letters) :-

10. Father’s name (husbands’ name in the case of female Government servant ) :-

11. Designation at the time of retirement :-

12. Name of the office Department in which employed :-

13. Date of Birth in Christian era :-

14. Date of retirement :-

15. Fraction of pension proposed to be commuted :-

16. Disbursing authority from which pension is to be drawn after retirement-
(a) Name and complete address of the Treasury/Sub-Treasury
(b) (i) Branch of the nominated Nationalized Bank
With complete postal address:-
(ii) Bank Account No. to which monthly
Pension is to be credited each month :-
© Accounts Office of the Ministry/Department/Office:-

Signature

Place:_ Present Postal address

Date:- ………………………………..
Postal address after retirement.
………………………………..

25
 PART-II

(ACKNOWLEDGEMENT)

Received from Sri/Smti/Kumari…………………………………..application in Part-I of Form I-A

for commutation of pension without medical examination.

Place:-
Date:-
Signature of Head of Office

PART-III

Forwarded to the Director of Audit and Pension, Govt. of Arunachal Pradesh, Naharlagun with
the remarks that ------

(i) The particulars furnished by the applicant inn part-I have been verified and and are correct.
(ii) The applicant is eligible to get pension commuted without medical examination.
(iii) The commuted value of pension determined with reference to the Table applicable at present
comes to Rs.________ ; and
(iv)The amount of residuary pension after commutation will be Rs._____________.

2. The pension papers of the applicant completed in all respect were forwarded under this Office
letter No.___________________________________dated_____________.It is requested that the
payment of the amount of the commuted value of pension may be authorized through PPO.
3. The receipt of the part-I of this form has been acknowledged in part –II which has been
separately forwarded to the applicant on _________________.

4. The commuted value of pension is debitable to H/A ___________.

Place:-
Date :-

Sig. Head of Office

26
 Pension calculation sheet
1. Name of the Pensioner :-

2. Date of birth :-

3. Date of entry into Govt. service :-

4. Age at entry:-

5. Date of quitting the service/retirement :-

6. Age at quitting the service /retirement :-

7. Total length of service :-

8. Non-qualifying service (if any) :-

9. Net qualifying service ( 7-8 ) :-

10. Last pay ( Band Pay + GP+SP+NPA) :-

11. Average emoluments for pension ( Band pay +GP+SP+NPA) of last 10 months :-

12. Emolument for calculation of pension

(Amounts at sl.10 or 11 whichever is more) :-

13. Amount of pension ( 50% 0f the emoluments at 12 above) :-

14. Amount of Gratuity =

i.e. Emoluments (Last Band Pay+GP+SP+NPA+DA)
X Six monthly completed period of service :-
4
(Subject to maximum of 16 1/2 times the emoluments or Rs. 10,Lakh ).

15. Amount of family pension:-

(i) Enhanced rate (50% of emoluments at 12 above ) :-
(For a period of seven years or for a period upto the date
on which the deceased Government servant would have
attained the age of 65 years/67 years, as the case may be,
had he survived whichever is less.)
(ii) Normal rate (30% of emoluments at 12 above subject to minimum of Rs. 3500/- p.m. ) :-

16.Commutation of pension ( maximum of 40% of Pension at 13 ) :-

( Commuted factor x 12 x Amount offered for commutation)

17. Recoveries due :-

(i)…….
(ii)…….

Sig.of Assistant Sig. of Head of office

27
LAST 10 MONTHS PAY IN RESPECT OF SRI/SMTI/LATE………………………………………….

Sl.no Basic pay Special pay/NPA Grade Pay Monthly total

Emoluments
1 2 3 4 5
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total=

Average emoluments of last 10 months=

Sig. of DDO/Head of office

28
 LAST PAY CERTIFICATE.

Last Pay certificate of Sri/Srmti………………………………………………

Office of the ………………………………………………………proceeding on retirement has been paid
upto …………………………………in the Pay Band -2 Rs…………….per month at the following rates
—

1. Pay :-
2. Special pay :-
3. Grade Pay :-
4. Dearness Allowance :-
5. Special compensatory allowance :-
_________________
Total –
_________________

2. His General Provident Account No………………….. is maintained by the Director of Accounts

and Treasuries, Naharlagun.
3. He /She has made over charges on …………………………….

Deductions/Recoveries

1. GPF contribution @ Rs. ………deducted upto………….. and credited to his GPF A/C
No……………………….
2. CGEGIS both Saving s and Insurance Fund @ Rs. ………per month deducted upto……………
3. Rs. ………….. being water charges deducted upto………………..
4. Rs. …………..being civic charges deducted upto………………….

Details of payments made as provisional pension and gratuity –

1. Provisional Pension-Rs……….
2. Provisional gratuity-Rs……….

Signature of the DDO

29
 NO DEMAND CERTIFICATE
( To be obtained from the Head of office)

30
 VIGILANCE CLEARANCE
( To be obtained from the Vigilance Department of the Government of Arunachal Pradesh, Itanagar)

31
 LOAN CLEARANCE CERTIFICATE
( To be obtained from the Director of Accounts and Treasuries, Govt. Of Arunachal Pradesh, Naharlagun)

SPECIMEN SIGNATURE AND DESCRIPTIVE ROLL OF

SRI/SMTI……………………………………….

1. SPECIMEN SIGNATURE:------

(i)……………………………

(ii)…………………………….

(iii)……………………………

2. DESCRIPTIVE ROLL OF SRI/SMTI…………………………………………..

1. Height :-

2. Personal identification mark :-

Witness:-
Name Full address Signature

1…………………............... …………………….. ………….

…………………….
……………………..

2…………………………. …………………….. ………….

…………………….
…………………….

Attested by

Head of Office /Any gazetted Officer

with official seal.

32
 SPECIMEN SIGNATURE AND DESCRIPTIVE ROLL OF
SRI/SMTI……………………………………….

1. SPECIMEN SIGNATURE:------

(i)……………………………

(ii)…………………………….

(iii)……………………………

2. DESCRIPTIVE ROLL :-

3. Height :-

4. Personal identification mark :-

Witness:-
Name Full address Signature

1…………………............... ……………………….. ………….

……………………….
……………………….

2…………………………. ……………………… ………….

……………………...
……………………..

Attested by

Head of Office /Any gazetted Officer

with official seal.

33
 FORM 23
See Rule 38(3)

Form of Medical certificate.

( In case of invalid pension)

Certified that I/We have carefully examined Sri/Smti/Kumari…………………………………….s/o

Sri/Late………………………………….a Government servant in the Department of …………………
………………….. His age by his/her own statement is …………years, and by appearance
about……..years. I/We consider Sri/Smti/Kumari……………………………….…….to be completely
and permanently incapacitated for further service of any kind in the Department to which he belongs in
consequence of …………….(here state disease or cause).

Place :-
Date :-
Medical Authority.

34
 1. Passport size photograph/Joint Photograph (Husband and wife, if both are alive) --
3(Three) copies duly attested by the Head of Office.

1. SERVICE BOOK with following entries:-

(I) Date of retirement/absorption in

autonomous body/with copy of order
.
(ii) Payment /Non Payment of provisional
Gratuity and Pension with reference of
sanction order, if sanctioned.

(iii) Date of acceptance of Voluntary

Retirement with copy of order.

(iv) Date of Membership in UTEGIS,1984.

(v) Date of change of Group with rate of

subscription.

(vi Enhanced rate of subscription from 1-1-1990

(vii) Date of cessation from membership.

35
 (Application for Pensioner’s Identity card)

To

The Director of Audit and Pension

Government of Arunachal Pradesh,
Naharlagun.

Sub:-Issue of Pensioners Identity card –request for

Sir,

I would like to request you to issue me Pensioner’s identity card. My full particulars as required
are furnished as under-
1. Name:-

2. Residential address after retirement:-

3. Blood Group :-

4. Pay scale at retirement :-

5. Last Pay :-

6. Date of Birth:-

7. Date of retirement :-

8. Post held at retirement :-

2. Further I am enclosing herewith the following—

(i) Two Stamp size photographs
(ii) Copy of the Treasury challan No……………dated………..
For Rs. 50/- deposited into Head of Account “007 – other
Administrative services” being the cost of the I/card.

Yours faith fully

Signature…………………….

Name ……………………….

Designation………………….

36
OFFICE OF THE ………………………..

Application for payment of dues under, UTGEGIS, 1984.

Of

Name and Designation

of Government servant :-…………………………..

Date of Cessation
of Membership :-…………………

37
 FORM No. 4
(See Para 11.1)

To

The …………………………
……………………………..
……………

Sub:- Application for payment of accumulation under Union Territory Government Employees’
Group Insurance Scheme 1984.

Sir,

I have been a member of Union Territory Government Employees’ Group Insurance

Scheme,1984, since…………2 I have retired from service after attaining the age of ……….. years. I have
ceased to be in the employment with the Central/State Government with effect from…….…… .I was
holding the post of ……………………………. before retirement /cessation of the employment with the
Government . I request that the amount due to me under the Union Territory Government Employees’
Group Insurance Scheme may be paid to me.

Yours faithfully

Name of the Government servant.

Place :-
Date:-

__________________________________________________________________________________
1. Designation and address of the Head of Office.
2. Month and year of becoming a member of the scheme.

38
 FORM No. 8
(See para 19.7)

NOMINATION FORM THE BENEFITS UNDER THE UNION TERRITORY GOVERNMENT

GROUP INSURANCE SCHEME, 1984.

( When the Government servant has af family and wishes to nominate one member or more than one member thereof )

I…………………………………………………………….hereby nominate the 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 Government under the Union Territory
Government Employees’ group Insurance Scheme,1984,in the event of my date while in service or which
having become payable on my attaining the age of superannuation may remain unpaid at my death.
Name(s) and Relationship with Age * share of amount Contingencies on Name and address
address(es)of the Government to be paid to each the happening of and relationship
nominees servant which the of the person, if
nomination shall any, to whole the
become invalid right of the
nominee shall
pass in the event
of predeceasing
the Government
servant .
(1) (2) (3) (4) (5) (6)
1.

3.

N.B.-The Government servant should draw lines across the blank space below his last entry to prevent insertion of any names
after he has signed.

Dated this ……………………..day of ………………..20……at …………………..

Two witnesses

1.

2.

Signature of the Government servant.

*This column should be filled up so as to cover the whole amount of that may be payable under the scheme.

39
 FORM No. 9
(See para18)

UNION TERRITORY GOVERNMENT EMPLOYEES’GROUP INSURANCE SCHEME 1984

REGISTER OF MEMBER
GROUP

Section: I Particulars of employees subscribing to the Insurance Fund only.

Sl.No. Name Designation Date of Date of Date of Date of Date of Remarks

Birth appointment Commencement promotion to death
of subscription higher
groups/transfer
to other
Department.
(1) (2) (3) (4) (5) (6) (7) (8) (9)

Section II : I Particulars of employees subscribing to the Insurance Fund and the Savings Fund.

Sl.No. Name Designation Date of Date of Date of Date of Date of Remarks

Birth appointmen Commenc promotion to cessation of
t ement of higher membership
subscripti groups/transfer and reason
on to other thereof
Department.
(1) (2) (3) (4) (5) (6) (7) (8) (9)

Signature of the Head of office

40
 FORM No.13
(See para 6)

UNION TERRITORY GOVERNMENT EMPLOYEES’ GROUP INSURANCE SCHEME,1984.

Date of joining Date of Group to Rate of monthly Period Events with Remarks
Government admission to which contribution(in Rupee) exact date
service the UTGEGIS admitted From To affecting
cols.(3)
and (4)
(1) (2) (3) (4) (5) (6) (7)

Signature of the Head of office

41
 ANNEXTURE-C

RECEIPTED BILL

Received the sum of Rs…………..(Rupees…………………………………the total of entitlement

of Rs……….. from the Insurance Fund or Rs.……………from the Savings Fund to
Sri/Smti……………………………………..Designation…………………….group* A/B/C/D under the
Union Territory Government Employees’ Group Insurance Scheme, 1984.

Date: Signature(s) of the Recipients(s)

(Name in Block Letter)
______________________________________________________________________________
* Delete whichever is inapplicable.

FOR USE IN DEPARTMENTAL OFFICE

(a) Relevant biodata of the member.

1. Type of Group of the member (i.e. lowest group)Viz. D/C/B/A on initially joining the
scheme on……………
2. Year of acquiring membership of higher group---
(i) C ……………
(ii) B ……………
(iii) A …………...
(b) Countersigned for payment of Rs. …….. ( Rupees……………………………………………)
to claimant(s) crossed cheques/Demand draft to be issued in favoure of the claimant(s)

Date :
Signature of the DDO

FOR USE IN THE DIRECTOR OF AUDIT AND PENSION OFFICE

Passed for payment of Rs………….(Rupees………………….). Payment through Cheque(s)

No……..

Date : Director of Audit and Pension

42
 OFFICE OF THE ……(Name of the office)………………………..

No……………… Date……………………
ORDER

Sanction is hereby accorded for an amount not exceeding Rs……… ..Rupees…………) in

favoure of Sri/Smti………………………………………..being the accumulated amount of Savings Fund
under UTGEGIS,1984 on his retirement / Voluntary retirement /absorption of autonomous Body
on……………….

The expenditure is debitable to the Head of Account ‘8011 Insurance and Pension Fund’ of
Union Territory Government Employees’ Group Insurance Scheme,1984.

Signature of the Head of Office

Memo No……………………………………. Date ……………………….

Copy t:-
1…………….
2…………….

Signature of the Head of Office

43