FORM-5 ANNEXURE

Particular to be obtained by the Head Office from the retiring Government Servant before eight
months of the Date of retirement.

1 Name of the Government Servant

2 Date of Birth/Retirement
3 Two specimen signature duly attested Enclosed
(furnished in a separate sheet)
4 *Three copies of the passport size joint Enclosed
photographs of the Govt. Servant with
his/her wife/husband
5 Two slips showing the particulars of Enclosed
height and personal identification marks
duly attested.
6 Present Address

7 @ Address after retirement

Phone No.
8 Name of the Treasury/public sector
Bank Branch Through which the
Government Servant wants to draw his
pension
9 @@ details of the family in form-3

Place :
Signature
Designation
Ministry/Deptt/Office:

Two slips each bearing the left hand finger impressions duly attested, may be furnished by a person
who is not literate enough to sign his name, if such a Govt. Servant on account of physical disability
is unable to give left hand thumb and finger impressions, he may give thumb and finger impressions
of the right hand, where a Government Servant has lost both the hands, he may give his toe
impressions, impressions should be duly attested.
*Only two copies of passport size photographs of self need be furnished.
(1) If the Government Servant is governed by rule 55 of the CCS (Pension) Rules, 1972 and is
unmarried or a widower or widow.
(2) If the Government Servant is governed by rule 55 of the CCS (Pension) Rules, 1972.
**where it is not possible for a Govt. Servant to submit a photograph with his wife/her
husband he/she may submit separate photographs. The photographs shall be attested by the
Head of Office.
@Any subsequent change of address should be notified to the Head of Office/Audit Office.
@@ Applicable only where rule 54 of the CCS (Pension) Rules applies to the Govt.
Servant.
 FORM-2
(When the Officer has a family and wishes to nominate one member thereof)

I hereby nominate the person mentioned below which is member of my family and confer
on him the right to receive any gratuity that may be sanctioned by Government in the event of my
death while in service and the right to receive on my death any gratuity which having become
admissible to me on retirement may remain unpaid at my death.

Name and Relationship with Age Contingencies on the Name, address & relationship of Amount or
Address of the officer having which the the person or persons, if any, to share of
nominee nomination shall whom the right conferred on grauity
become invalid nominee shall pass in the event payable to
of the nominee predeceasing the each*
officer of the *nominee dying
after the death of the officer but
before receiving payment of the
grauity

This nomination supercedes the nomination made by me earlier on which stands cancelled:
Dated this Day of 20___

Witness to Signature
1-

Signature of Officer

2-

To be filled in by the Head of Office in the case of a non gazetted officer.

Nomination by

Designation Date Signature of Head of Office

*This column should be filled in so as the cover the whole amount gratuity.
 FORM-3
(SEE RULE 54(12)

Details of Family
Name of the Government Servant

Designation : Date of Birth:

Date of appointment :

Details of the members of My family as on

S.No. Name of the member of Date of birth- Relationship Initials of the Remarks
family age with the head of office
officer

I hereby undertake to keep the above particulars up-to-date by notifying to the Accounts
Officer/Head of office any addition or alternation.

Signature of Govt. Servant

Place :
Date :

*Family for this purpose means:

(a) Wife in the case of a male Govt. Servant.
(b) Husband in the case of female Govt. Servant.
(c) Sons below 21 years of age and unmarried daughters below 24 years of age including
such sons or daughters adopted legally before retirement.

Note : Wife and Husband shall include respectively judicially separated wife and husband.
 FORM-D

FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF

SUPERANNUATION PENSION WITHOUT MEDICAL EXAMINATION WHEN
APPLICANT DESIRES THAT THE PAYMENT OF THE COMMUTED VALUE OF
PENSION SHOULD BE AUTHORISED THROUGH THE PENSION PAYMENTS ORDER.

(To be submitted in duplicate 3 months before the date of retirement)

Part-I
To,
The Chief Secretary to the Government of U.P.
LUCKNOW.

Subject: COMMUTATION OF PENSION WITHOUT MEDICAL EXAMINATION.

Sir,
I desire to commute a fraction of my pension in accordance with the provisions of the AIS
(Communication of Pension) Regulation 1959. The necessary particulars are furnished below:

1 Name of the Government Servant

2 Father's name (and husband's name in
the case of female Member of the
service)
3 Designation
4 *Name of Office/Department/Ministry
in which posted
5 Date of Birth (by Christian era)
6 Date of retirement on superannuation or
on the expiry of Extension in service
7 Fraction of superannuation pension
proposed to be Commuted
8 Disbursing authority from which
pension is to be drawn after retirement
(a) Treasury/Sub Treasury (Name and
complete address of the Treasury/Sub
Treasury Office indicated)
(i) Branch of the nationalized bank with
complete postal address
(ii) Bank account No. to which monthly
S.B.A./ No.
(b) Designation and address of the Accounts
Officer (Applicable in a case where the
pension is proposed to be drawn through
an Account Officer other than the A.O.
Issuing the P.P.O.

Signature

Present Postal
Address:

Postal Address
after retirement:

Place :
Date :

NOTE : The payment of commuted value of pension shall be made through the disbursing authority
from which pension is to be drawn after retirement. It is not open to an applicant to draw the
commuted value of pension from a disbursing authority other than disbursing authority from which
pension is to be drawn.
 INDEMNITY BOND
This deed of indemnity is made on the _____________ date of _______________ 20______
corresponding to Saka Samvat the ______________ day of ___________ 200_________
SHRI____________________________________S/o__________________________________
Resident of ______________________________________________________________(Bounden)
Favour the Governor of Uttar Pradesh (called "the Governor"------------------ whereas:-

The Bounden above name was/is in the service of the Government of Uttar Pradesh (called
"Government") as ____________________ (Designation) in _______________________________
________________________ (name of office).

The bounden above name has retired/is due for retirement. A No demand certificate is required to
be issued in favour of the bounder by_______________________________________ before
sanction of pension gratuity etc. to the Bounden but the said certificate could not be issued so far
and the scrutiny or records for that purpose is likely to take further time.

The Government is willing to sanction pension and gratuity etc. To this Bounden of condition that
the Bounden shall execute a bond, being these presents, to indemnify and save harmless the
Government from any loss which the government may incur by reason of any moneys found due
against the bounden within a period of two years from the date of retirement of the Bounden.

NOW THIS DEED WITNESSES-

1) In consideration of Government agreeing to sanction pension and gratuity etc. to the
Bounden before issue of "No demand Certificate" in this favor, the Bounden hereby
covenants with the Governor that the bounden shall pay on demand to the Government all
moneys which may be discovered: within a period of two years from the date of retirement
of the Bounden: to be
2) Any amount due under this deed may; on the certificate
of__________________________________ which shall be final: conclusive and binding on
the Bounden: be recovered from him as arrears of land revenue.

In witness to the above written bond and the conditions there of the Bounden has signed hereunder
on the day and year first above written.
The stamp duty on this instrument will be borne by the Government.

Witness:-
Signed by Bounden
(1)………………………………………..
Address………………………………….
…………………………………………..
………………………………………….

Witness:-
(2)………………………………………..
Address………………………………….
…………………………………………..
………………………………………….
 FORM-E

FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF

PENSION WITHOUT MEDICAL EXAMINATION

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

Part-I
To,
The Chief Secretary to the Government of U.P.
LUCKNOW.

Subject: COMMUTATION OF PENSION WITHOUT MEDICAL EXAMINATION.

Sir,
I desire to commute a fraction of my pension as indicated below in accordance with the
provisions of the All India Service (Communication of Pension) Regulation 1959. The necessary
particulars are furnished below:

1 Name of the Government Servant

2 Father's name (also husband's name in

the case of female Member of the
service)

3 Designation of the post held at the time

of retirement
4 *Name of Office/Department/Ministry
in which posted
5 Date of Birth (by Christian era)
6 Date of retirement
7 Class of pension on which retired (i.e.
superannuation pension, retiring pension
etc.)
8 Amount of pension authorized
(In case final amount of pension has not
been authorized indicate the amount of
anticipatory pension sanctioned under
rule 27 of AIS (DORD) rules 1959)
9 Fraction of pension proposed to be
commuted
10 Designation of Accounts Officers who
authorized the pension and the No. and
date of pension payment order, if issued.
11 Disbursing authority for payment of
pension
(a) Treasury/Sub Treasury (Name and
complete address of the Treasury/Sub
Treasury Office indicated)
(b) (i) Branch of the nationalized bank with
complete postal address
(ii) Bank account No. to which monthly
pension is being credited each month

(c) Designation and address of the Accounts

Officer (Applicable in a case where
pension is being drawn through an
Accounts Officer other than the
Accounts Officer who issued the P.P.O.)

Signature

Postal Address
after retirement:

Place :
Date :

NOTE : The payment of commuted value of pension shall be made through the disbursing authority
from which pension is being drawn drawn. It is not open to an applicant to draw the commuted
value of pension from a disbursing authority other than disbursing authority from which pension is
to be drawn.
 Particulars of height and personal identification marks of
Govt. Servant

1. Height

2. Identification mark

ATTESTED
 SPECIMEN SIGNATURE OF GOVT. SERVANT

1.

2.

Signatures Attested