PENSION - SINGLE COMPREHENSIVE FORM

                                                        SINGLE COMPREHENSIVE FORM

                                                                    (As per Memo No.359-F(Pen) dt. 16.04.2009)


                      PLEASE FILL IN ALL THE ITEMS PROPERLY AND CAREFULLY. IN CASE A PARTICULAR ITEM IS NOT APPLICABLE, PLEASE STATE SO. BUT DO NOT LEAVE THE ITEM BLANK. THIS FORM NOT COMPLETED IN ALL RESPECTS WILL NOT BE ACCEPTED AND A FRESH SINGLE COMPREHENSIVE FORM MAY BE CALLED FOR.


1.

Name of the Govt. employee

( IN BLOCK LETTERS)


2.

Designation of the Govt. employee


3.

Father's Name of the Govt. employee


4.

a.

Name of the recipient of family pension

(IN BLOCK LETTERS)


b.

Relationship with Govt. Employee.


5.

Address of the Govt. Employee:


a.

Present


b.

Permanent


6.

Address of the family pensioner (in case of death while in service/after retirement)

a.

Present


b.

Permanent.


7.

Nationality and Religion


8.

a.

Name of the Establishment last served/serving with address and Telephone No./FAX No.


b.

Name of the Department.


9.

Employer / PSA's Code No.


10.

a.

Status of the Govt. Employee (temporary/Perm ant)


b.

Whether work-charged employee


c.

Whether appointment is made on ad-hoc basis and if so, whether regularised subsequently (enclose copy of Govt. Order).



11.

Whether a member of General Provident Fund (GPF). If so, quote GPF Account No.


12

If anytime whether he was a member of Contributory Provident Fund (CPF). If si, quote GPF Account No.


13

If he was a member of Contributory Provident Fund (CPF). Whether the employer's the employer's share of CPF along with interest accrued thereon has been credited to the Govt. Account (With full particulars mentioning the period for which refund made)


14.

Pension Rules and relevant Govt. order applicable in this case.


15.

Class of pension applicable.


16.

Govt./Non-Govt. Organization under which service has been rendered (in order of employment & showing the period served.


17.

a.

Date of Birth of the Government employee (by Christian era)


b.

Date of appointment.


c.

Date of Retirement/Death


d.

Period of gross service.


e.

Period of War/Military Service, if any.


f.

Details of periods(s) of Service on deputation terms to Government undertaking/ Autonomous bodies Local Bodies etc, if any: N.A.


Organization.

From (Date)

To (Date)

Remarks

Contribution Received (Yes/No).






g.

Amount and nature of pension/ gratuity received for Military service.


h.

Whether opted for Family Pension on account of Military service.



18.


Non-qualifying service



a.

EOL without medical certificate




b.

Period of suspension not to be counted towards pension etc.



c.

Other non qualifying service, if any.



19.


Net qualifying service ( Grosss service minus non-qualifying service)


20


Weight age of Service admissible, if any. (Employee retired on or after 25.2.2009, the benefit of weightage under rule 27 of WBS (DSRB) Rules, 1971 is not applicable.


21.

Total Service qualifying for pensionary benefits (19+20)



a.

Last pay drawn with Scale of Pay


b.

Proposed superannuation Pension/ Retiring Pension/invalid Pension/Prorata pension/ Compensation Pension.


c.

Proposed Retiring Gratuity/Death Gratuity


d.

Proposed Family Pension, if applicable.


22.


Date on which the Government Employee /Family Pensioner applied for pension.


23.


Date from which the pension/family pension is to commence.


a

Whether commutation of pension wanted.



If so the amount/portion of the pension to be commuted.


b

Date on which the application for commutation has been received by the pension sanctioning authority.



c

The proposed amount of the reduced pension ( In case commutation applied and sanctioned)


d

Proposed amount of Reduced Pension (in case commutation applied and sanctioned.


e

Proposed amount of CVP (Enclose application for commutation in prescribed form duly accepted by PSA)



24.

Place of payment of Pension/Family pension. (State clearly the name of Treasury with Unit No. i.e. I or II) if payment is desired in West Bengal).



Name of the Treasury/PAO (With Unit No. i.e. I or II) with which Pension Sanctioning Authority is attached.


26

Whether payment of pension/family pension is desired through a Public Sector Bank Within the jurisdiction of Kolkata Corporation area, if so:


a.

Name of the Bank & Branch (with B.S.R. Code No. of the Paying Branch as well as Link Branch.


b.

S/B A/c No. (in single name/joint name) (Enclose Annexure A in duplicate )


27.

Descriptive Roll of the pensioner/family pensioner (enclose descriptive rill in 3 separate sheets with the following information):


(i)

Height


(ii)

Identification Marks.


(iii)

Left thumb and finger impression

Thumb

Fore finger

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)

28.

Statement of family members (including unmarried/widowed/divorced daughter beyond 25 years and physically crippled and mentally retarded son/daughter beyond 25 years.

S.NO.

Name(s)

Date of Birth

Age

Relationship with category

Marital Status

Date of Marriage.

1.

2.

3.







29.

a.

Whether nomination made for LTA Pension/LTA Family Pension


b.

If so, state the name of the nominee (Enclose the nomination paper in duplicate).


c.

If not, state the names of the legal heir(s), his/her//their age, share payable and relationship with the deceased pension/family pensioner where LTA of pensionary benefits are payable.




(FOR DEATH CASES ONLY) : N.A.

30.

a.

Whether nomination made for death-gratuity (yes/no)


b.

If so, state the name(s) of the nominee(s), his/her/their relationship with the Govt. employee and share payable.



(Enclose two copies of the duly accepted nomination form – one is Service Book and other with pension papers)

c.

State below the the details of surviving family members (Defined in Rule 7 (1) (e)(i) of the W.B.S. (DCRB) Rules, 1971)

STATEMENT OF FAMILY MEMBERS

S. No.

Name(s)

Date of birth

Age

Relationship with category.

Marital Status

Date of Marriage.








N.B. Daughters married before death of Govt. employee do not fall in the defintion of Family for the purpose of Death Gratuity.

31.

Outstanding of the Govt. employee


a).

House Building Advance.


b).

Marriage and Illness Advance.


c).

Cycle/Scooter/Car Advance/Computer Advance


d).

Festival Advance


e).

Overdrawal of pay/allowances, if any with the Head of Account under which it is to be credited.


f).

Any other outstanding dues with Head of Account under which it is to be credited.


32.

a)

Provisional Pension/Family Pension paid, if any (Please state the rate and the period for which paid)


b)

Provisional gratuity/death gratuity paid, if any.


c)

Interim Relief paid, if any.



33.

Head of Account to which pension/gratuity is chargeable


34.

a)

Whether the Government employee is re-employed after retirement.


b)

If so, details of re-employment and fixation of reemployed pay may be stated with necessary order of competent authority.


35.

a)

Whether the family pensioner is employed (widow/widower).


b)

Whether the family pensioner is receipt any other Pension/Family Pension. If so, details with supporting documents.


36.

Please state the name of legal guardian who will draw the share of LTA pension/family-pension/gratuity/ death gratuity in favour of minors.


37.

Whether any vigilance case/Court case/Department or criminal proceedings is pending against the Govt. Employee. If so, give details with supporting documents.


38.

Any other Remarks






















39. (A). 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 the full pension/family pension, death-cum-retirement gratuity which may be accepted by the Accountant General & as admissible under the rules.

Or

(B). The undersigned having satisfied himself that the service of ................................ has not been thoroughly satisfactory here by orders that the full pension/family pension/death-cum-retirement 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 of percentage of reduction pension/family pension…………..Amount or percentage of reduction in gratuity………………… The grant of pension/family pension, death-cum-retirement gratuity…..............................……………..

(Inapplicable portion should be scored out)

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.




                                                                            Signature………………………………..



                                                                                Full Name……………………………………..

                                                                        Designation of the Pension Sanctioning Authority

                                                                                Secretary, Govt. of West Bengal,

                                                                         Judicial Department, Writers’ Buildings,

                                                                                           Kolkata- 700 001.



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