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.
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1.
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Name of the
Govt. employee
( IN BLOCK LETTERS)
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2.
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Designation of
the Govt. employee
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3.
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Father's Name
of the Govt. employee
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4.
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a.
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Name of the
recipient of family pension
(IN BLOCK LETTERS)
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b.
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Relationship
with Govt. Employee.
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5.
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Address of the
Govt. Employee:
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a.
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Present
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b.
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Permanent
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6.
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Address
of the family pensioner (in case of death while in service/after
retirement)
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a.
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Present
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b.
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Permanent.
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7.
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Nationality and
Religion
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8.
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a.
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Name of the
Establishment last served/serving with address and Telephone
No./FAX No.
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b.
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Name of the
Department.
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9.
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Employer /
PSA's Code No.
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10.
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a.
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Status of the
Govt. Employee (temporary/Perm ant)
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b.
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Whether
work-charged employee
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c.
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Whether
appointment is made on ad-hoc basis and if so, whether regularised
subsequently (enclose copy of Govt. Order).
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11.
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Whether a
member of General Provident Fund (GPF). If so, quote GPF Account
No.
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12
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If anytime
whether he was a member of Contributory Provident Fund (CPF). If
si, quote GPF Account No.
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13
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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)
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14.
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Pension Rules
and relevant Govt. order applicable in this case.
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15.
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Class of
pension applicable.
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16.
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Govt./Non-Govt.
Organization under which service has been rendered (in order of
employment & showing the period served.
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17.
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a.
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Date of Birth
of the Government employee (by Christian era)
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b.
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Date of
appointment.
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c.
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Date of
Retirement/Death
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d.
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Period of gross
service.
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e.
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Period of
War/Military Service, if any.
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f.
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Details of
periods(s) of Service on deputation terms to Government
undertaking/ Autonomous bodies Local Bodies etc, if any: N.A.
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Organization.
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From (Date)
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To (Date)
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Remarks
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Contribution
Received (Yes/No).
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g.
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Amount and
nature of pension/ gratuity received for Military service.
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h.
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Whether opted
for Family Pension on account of Military service.
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18.
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Non-qualifying
service
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a.
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EOL without
medical certificate
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b.
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Period of
suspension not to be counted towards pension etc.
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c.
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Other non
qualifying service, if any.
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19.
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Net qualifying
service ( Grosss service minus non-qualifying service)
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20
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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.
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21.
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Total Service
qualifying for pensionary benefits (19+20)
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a.
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Last pay drawn
with Scale of Pay
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b.
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Proposed
superannuation Pension/ Retiring Pension/invalid Pension/Prorata
pension/ Compensation Pension.
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c.
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Proposed
Retiring Gratuity/Death Gratuity
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d.
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Proposed Family
Pension, if applicable.
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22.
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Date
on which the Government Employee /Family Pensioner applied
for pension.
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23.
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Date from which
the pension/family pension is to commence.
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a
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Whether
commutation of pension wanted.
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If so the
amount/portion of the pension to be commuted.
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b
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Date on which
the application for commutation has been received by the pension
sanctioning authority.
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c
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The proposed
amount of the reduced pension ( In case commutation applied and
sanctioned)
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d
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Proposed amount
of Reduced Pension (in case commutation applied and sanctioned.
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e
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Proposed amount
of CVP (Enclose application for commutation in prescribed form
duly accepted by PSA)
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24.
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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).
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Name of the
Treasury/PAO (With Unit No. i.e. I or II) with which Pension
Sanctioning Authority is attached.
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26
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Whether payment
of pension/family pension is desired through a Public Sector Bank
Within the jurisdiction of Kolkata Corporation area, if so:
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a.
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Name of
the Bank & Branch (with B.S.R. Code No. of the Paying
Branch as well as Link Branch.
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b.
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S/B A/c No. (in
single name/joint name) (Enclose Annexure A in duplicate )
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27.
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Descriptive
Roll of the pensioner/family pensioner (enclose descriptive rill
in 3 separate sheets with the following information):
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(i)
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Height
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(ii)
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Identification
Marks.
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(iii)
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Left thumb and
finger impression
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Thumb
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Fore finger
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Middle finger
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Ring finger
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Little finger
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(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)
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28.
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Statement
of family members (including
unmarried/widowed/divorced daughter beyond 25 years and physically
crippled and mentally retarded son/daughter beyond 25 years.
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S.NO.
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Name(s)
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Date of Birth
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Age
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Relationship
with category
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Marital Status
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Date of
Marriage.
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1.
2.
3.
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29.
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a.
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Whether
nomination made for LTA Pension/LTA Family Pension
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b.
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If so, state
the name of the nominee (Enclose the nomination paper in
duplicate).
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c.
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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.
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(FOR
DEATH CASES ONLY) : N.A.
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30.
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a.
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Whether
nomination made for death-gratuity (yes/no)
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b.
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If so, state
the name(s) of the nominee(s), his/her/their relationship with the
Govt. employee and share payable.
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(Enclose two
copies of the duly accepted nomination form – one is Service
Book and other with pension papers)
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c.
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State below the
the details of surviving family members (Defined in Rule 7 (1)
(e)(i) of the W.B.S. (DCRB) Rules, 1971)
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STATEMENT
OF FAMILY MEMBERS
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S. No.
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Name(s)
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Date of birth
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Age
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Relationship
with category.
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Marital Status
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Date of
Marriage.
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N.B. Daughters
married before death of Govt. employee do not fall in the
defintion of Family for the purpose of Death Gratuity.
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31.
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Outstanding of
the Govt. employee
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a).
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House Building
Advance.
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b).
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Marriage and
Illness Advance.
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c).
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Cycle/Scooter/Car
Advance/Computer Advance
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d).
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Festival
Advance
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e).
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Overdrawal of
pay/allowances, if any with the Head of Account under which it is
to be credited.
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f).
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Any other
outstanding dues with Head of Account under which it is to be
credited.
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32.
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a)
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Provisional
Pension/Family Pension paid, if any (Please state the rate and the
period for which paid)
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b)
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Provisional
gratuity/death gratuity paid, if any.
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c)
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Interim Relief
paid, if any.
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33.
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Head of Account
to which pension/gratuity is chargeable
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34.
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a)
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Whether the
Government employee is re-employed after retirement.
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b)
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If so, details
of re-employment and fixation of reemployed pay may be stated with
necessary order of competent authority.
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35.
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a)
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Whether the
family pensioner is employed (widow/widower).
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b)
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Whether the
family pensioner is receipt any other Pension/Family Pension. If
so, details with supporting documents.
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36.
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Please state
the name of legal guardian who will draw the share of LTA
pension/family-pension/gratuity/ death gratuity in favour of
minors.
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37.
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Whether any
vigilance case/Court case/Department or criminal proceedings is
pending against the Govt. Employee. If so, give details with
supporting documents.
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38.
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Any other
Remarks
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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.
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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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