Specimen of Form-25 (Revised, 2016)

PENSION FORM TO BE USED IN CASE OF SUPERANNUATION / RETIRING / INVALID /

COMPENSATION / COMPULSORY RETIREMENT

[To be issued by the Appointing Authority 90 days before superannuation / retirement of the
retiring Government servant ]

Subject: SANCTION OF PENSION ON SUPERANNUATION / RETIRING / INVALID /

COMPENSATION AND COMPULSORY RETIREMENT.

On attaining the age of superannuation / having applied for retiring / invalid /compensatory
pension vide application No. dated OR has been retired compulsorily
vide Notification No. dated issued by Mr. Mrs. Ms. S/O,
W/O, D/O Designation drawing pay/emoluments
Rs. . (Reckonable towards pension), in BS on basis
(Please indicate nature of appointment i.e Regular/Officiating or Acting charge/Current
Charge w.e.f. ) Personnel No CNIC No. Presently posted at
(office) place of posting) has
retired/has been permitted to retire/ is due to be retired/ has been retired compulsorily from
the Government service (tick whichever is applicable) on date, after availing LPR for
days/Leave encashment in lieu of LPR Rs. .
Pension Calculation:-
Gross Pension Rs.
Commutation Rs.
Net Pension Rs.
Other Benefits:-
i) Rs.
ii) Rs.
Rs.
iii)

Gratuity (in case where qualifying service Rs.

is 5 years or more but less than 10 years)

(1) His / her date of birth is Date of 1st entry into government service is
and EOL availed is days. Total length of qualifying service
for pension is _ years months _days.
(2) Certified that no inquiry is pending against him / her.
(3) Certified that no recovery is outstanding against him / her.
(4) Certified that:-
i) Advances drawn (if any) stand fully repaid, along with interest.
ii) An amount of Rs. On account of (HBA, MCA/etc)
principal amount alongwith interest is outstanding which may be
recovered from the pension.
(5) Anticipatory pension upto ( %) of full pension is sanctioned as admissible to
him/her under section 19(2) of Civil Servant Act, 1973 (in case of anticipatory
pension).
(6) Certified that deficiency / disciplinary / criminal case pending against the
aforementioned retired government servant has been finalized. Therefore, final
pension payment @ ( %) (After adjustment of already paid amount of
anticipatory pension) and commutation amounting %) (Subject to a maximum of
35% of gross pension), as determined by concerned Accounts office, may be paid.
(7) Undersigned is satisfied that the service of retiring employee has been satisfactory.
Administrative and financial sanction for grant of pension / commutation @
% upto maximum of 35% of gross pension, if so opted by the retiring government
servant, to be determined by the Accounts Office, is hereby accorded in favour of Mr.
/ Mrs/Ms through Bank/Post Office/ Treasury Account
No. (mentioned in DCS Form enclosed) as admissible under the
rules.
OR
(7-a) Undersigned is satisfied that the services of Mr./Mrs/Ms has not
been satisfactory and it has been decided that the full pension/ gratuity found to the
Audit/ Account Officer to be admissible under the rules should be reduced by the
specific amount or percentage given below:-
i) Amount or percentage of reduction in pension .
ii) Amount or percentage of reduction in pension .
iii) Sanction is hereby accorded to the grant of pension / gratuity as so
reduced.
(8) The payment of pension and / or gratuity may commence w.e.f .

Following documents attached.

(i) Pension application alongwith three attested photographs as “ Annex-A”
(ii) Notification of Retirement.
(iii) Last pay Certificate (LPC).
(iv) Pension contribution receipts / Bank Challan / acceptance certificate (In service
death).
(v) Original service book along with its attested copy / service statement (in case of
gazette Government servant).
(vi) N.D.C from Estate Office in case of Government accommodation.

Signature [By Name] with stamp

Official Seal Pension Sanctioning
Authority

1. The Accounts Office is requested to grant pension and endorse a copy of

computerized pension payment order (C.P.P.O) / Pension payment order (P.P.O) to
this department / office. The original service book after recording necessary entries
regarding issuance of C.P.P.O / PPO may also be returned to this department/office.
2. Mr./Mrs./Ms. ,you are hereby informed that your commutation (if
opted) and first monthly pension shall be transferred / credited by the Accounts
office in the bank /Post office /Treasury office .
Branch Account No. as
opted by you.

Important: As per requirement every pensioner is bound to provide life certificate to his/her
bank on or before 10th March and 10th September of each year (Annex-C).
 “Annex-A”
APPLICATION / CERTIFICATES TO BE GIVEN BY THE PENSIONER FOR PENSION /
GRAUITY / COMMUTATION
[to be given by retiring government servant for grant of pension in case of superannuation/ retiring/
invalid/ compensation/ compulsory retirement]
The Director (Personnel),
National Highway Authority,
Islamabad.

Dear Sir,

It is submitted that I Father / husband

Name: designation / post held _ BPS-
on (Please indicate kind of appointment i.e. Regular/Officiating or Acting
charge/Current charge w.e.f ) CNIC No. (copy enclosed)
Nationality , Personnel No. Cell No. (i)
(ii) , Gmail: , Postal Address:
that I
have retired/ have been permitted to retire from the Government service/ I’m due to retire/
has been retired compulsorily on . My pension / commutation / gratuity
may be transferred / credited by the Accounts Office in the bank / Post office / Treasury
office Branch Account No

{ DCS form ( where applicable) and list of family members, is enc losed}.

UNDERTAKINGS:-
1. I hereby declared that I am not in receipt of any other pension, military or otherwise except
PPO No. ,dated ,Amount ,Department
retired on .
2. Under Article 351 (B) of CSR: I hereby undertake that government may, within one year from
the issue of Pension Payment Order, recover any of its dues from the pension granted to me.
3. Article 351 (2) of CSR: I hereby declare that I shall not take part in any election or engage
myself in political activities of any kind within two years from the date of retirement.
4. In pursuance of Article 911 of CSR: I do hereby declare that I have neither applied for nor
received any pension/ commutation/ gratuity in respect of any portion of the service included
in this application and in respect of which pension/gratuity is claimed herein, nor shall I
submit any application hereafter without quoting a reference to this application and to the
order which may be passed thereon.
5. Under Article 920(1) of CSR: I hereby undertake to refund if the amount of pension granted to
me afterwards found to be in excess of that to which I am entitled under the regulation.
6. Under Article 922(a) of CSR: I do hereby declare that I have not received any pension or
gratuity in respect of any portion of the service included in this application.
7. I hereby opt for commutation @ (subject to a maximum of 35%) of my gross
pension.

Dated Name & Signature

of retiring Government Servant (Pensioner)

Note: Application to be verified by Pension Sanction Authority / DDO

Important: Every pensioner/family pensioner is bound to provide life certificate / Non-marriage

Certificate to his bank on or before 10th March 10th September of each year (Annex-
C).
 “Annex-C”
LIFE CERTIFICATE FORM

(This certificate is to be furnished on or before 10 th March and 10th September of each year to the
concerned bank/post office/treasury (pension payment office) in person or through representative
or by post/courier service)

This is to certify that Mr./Mrs./Ms. , S/o, W/o, D/o,

holder of PPO No. CNIC No.
Whose specimen signatures / thumb impression and address are appended below is alive till date
.

Date: (Pensioner’s Signature / Thumb Impression)

Phone No.
Address.

(Signatures of attesting officer

with date & Name Stamp)

NO MARRIAGE CERTIFICATE

(This certificate is to be furnished on or before 10th March and 10th September of each year to the
concerned bank/post office/treasury (pension payment office) in person or through representative
or by post/courier service)

I, Widow/Daughter of the deceased Mr./Mrs./Ms.

holder of Pension Payment Order No. hereby
declare that I have not been married during the last six months.

Date: (Pensioner’s Signature / Thumb Impression)

Phone No.
Address.

(Signatures of attesting officer

with date & Name Stamp)

NOTE: THE ABOVE CERTIFICATE(S) IS/ ARE TO BE SIGNED BY GAZETTED GOVERNMENT

OFFICER/MILITARY COMMISSIONED OFFICER / MAGISTRATE / SUB-REGISTRAR /
PENSIONED OFFIER / CHAIRMAN UNION COUNCILS/ MEMBER OF THE FEDERAL OR
PROVINCIAL ASSEMBLIES / MANAGER OF BANKS.
 NATIONAL HIGHWAY AUTHORITY

List of All Family Members of Mr/Mrs.

Sr Date of Marital Monthly
Name CNIC / Form-B Relationship Profession
# Birth Status Income

Signature:
Name:
Designation:
Attested
 NATIONAL HIGHWAY AUTHORITY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 APPLICATION FOR GP FUND
[to be given by retiring government servant for grant of GP Fund in case of superannuation/ retiring/
invalid/ compensation/ compulsory retirement]

The Deputy Director (GP Fund),

National Highway Authority,
Islamabad.

Dear Sir,

It is submitted that I have retired from service of NHA on . My GP

Fund dues may kindly be released as per rules and remitted to my Bank A/c
No. maintained at Bank,
Branch , at the earliest possible, please.

Name:
Date: Designation:
CNIC#
Contact #
Address:
 ID No. PER-NDC-
NATIONAL HIGHWAY
AUTHORITY

NO DEMAND CERTIFICATE

It is certified that there is nothing outstanding against Mr./Mrs.

Designation BS Nature of Appointment: (Tick

Regular / Contract / Deputation / Daily Wage / Individual Consultant being relieved

account of resignation / termination / dismissal / death / retirement or appointment

some other department vide office order No.

dated .

1. DD/AD (Concerned Office) Name Signature

2. DD /AD (Telephone Section) Name Signature

3. DD / AD (Accounts Section) Name Signature

4. DD/AD(Accounts-Estb), HQ Name Signature

5. DD/ AD (Store Section), HQ Name Signature

6. DD/ AD (Welfare Section), HQ Name Signature

7. Incharge NHA Library, HQ Name Signature

8. DD/AD (Transport Section), HQ Name Signature

9. DD/AD (CP-Fund Section), HQ Name Signature

10. DD/AD (Personnel Section), HQ Name Signature

11. DD/AD (MIS Section), HQ Name Signature

12. DD/AD Confidential Section), HQ Name Signature

13. DD/AD (Admn) Regions/Projects Name Signature

14. PD (Concerned Project) Name Signature

Concerned Officer / Official

Signature

Name

Designation

Date

Note: 1. The above mentioned officers, before signing the No Demand Certificate, shall
ensure that the officer/official being relieved has returned all the NHA’s items,
equipments, vehicle, dues, records, files or any other assets held by him.

2. The officers/officials posted in the Regions/Projects are required only to get

signature and clearance from officers mentioned at Sr. Nos. 1,3,13 & 14 above.
 ID No. PER-NDC-
NATIONAL HIGHWAY
AUTHORITY

NO DEMAND CERTIFICATE

It is certified that there is nothing outstanding against Mr./Mrs.

Designation BS Nature of Appointment: (Tick

Regular / Contract / Deputation / Daily Wage / Individual Consultant being relieved

account of resignation / termination / dismissal / death / retirement or appointment

some other department vide office order No.

dated .

1. DD/AD (Concerned Office) Name Signature

2. DD /AD (Telephone Section) Name Signature

3. DD / AD (Accounts Section) Name Signature

4. DD/AD(Accounts-Estb), HQ Name Signature

5. DD/ AD (Store Section), HQ Name Signature

6. DD/ AD (Welfare Section), HQ Name Signature

7. Incharge NHA Library, HQ Name Signature

8. DD/AD (Transport Section), HQ Name Signature

9. DD/AD (CP-Fund Section), HQ Name Signature

10. DD/AD (Personnel Section), HQ Name Signature

11. DD/AD (MIS Section), HQ Name Signature

12. DD/AD Confidential Section), HQ Name Signature

13. DD/AD (Admn) Regions/Projects Name Signature

14. PD (Concerned Project) Name Signature

Concerned Officer / Official

Signature

Name

Designation

Date

Note: 1. The above mentioned officers, before signing the No Demand Certificate, shall
ensure that the officer/official being relieved has returned all the NHA’s items,
equipments, vehicle, dues, records, files or any other assets held by him.

2. The officers/officials posted in the Regions/Projects are required only to get

signature and clearance from officers mentioned at Sr. Nos. 1,3,13 & 14 above.
 ID No. PER-NDC-
NATIONAL HIGHWAY
AUTHORITY

NO DEMAND CERTIFICATE

It is certified that there is nothing outstanding against Mr./Mrs.

Designation BS Nature of Appointment: (Tick

Regular / Contract / Deputation / Daily Wage / Individual Consultant being relieved

account of resignation / termination / dismissal / death / retirement or appointment

some other department vide office order No.

dated .

1. DD/AD (Concerned Office) Name Signature

2. DD /AD (Telephone Section) Name Signature

3. DD / AD (Accounts Section) Name Signature

4. DD/AD(Accounts-Estb), HQ Name Signature

5. DD/ AD (Store Section), HQ Name Signature

6. DD/ AD (Welfare Section), HQ Name Signature

7. Incharge NHA Library, HQ Name Signature

8. DD/AD (Transport Section), HQ Name Signature

9. DD/AD (CP-Fund Section), HQ Name Signature

10. DD/AD (Personnel Section), HQ Name Signature

11. DD/AD (MIS Section), HQ Name Signature

12. DD/AD Confidential Section), HQ Name Signature

13. DD/AD (Admn) Regions/Projects Name Signature

14. PD (Concerned Project) Name Signature

Concerned Officer / Official

Signature

Name

Designation

Date

Note: 1. The above mentioned officers, before signing the No Demand Certificate, shall
ensure that the officer/official being relieved has returned all the NHA’s items,
equipments, vehicle, dues, records, files or any other assets held by him.

2. The officers/officials posted in the Regions/Projects are required only to get

signature and clearance from officers mentioned at Sr. Nos. 1,3,13 & 14 above.
A-4 size paper
Light Yellow Form

FEDERAL EMPLOYEES BENEVOLENT AND GROUP INSURANCE FUNDS

BENEVOLENT FUND BUILDING, BLOCK C-II, NEAR ZERO POINT,
P.O.BOX NO.2035, ISLAMABAD

(Application form for Payment of Monthly Benevolent Grants and Lump Sum
Grant for Incapacitated Employee)
FORM-B
(See Rule 12)
PART-I
1. a) Name of the
Incapacitated employee

b) Father/Husband’s
Name

c) CNIC No.
 d) CNIC No. of Spouse (in case
of married employee)
e) Name of Parent Department and
Division/Ministry

f) Designation alongwith BPS

(Gazetted /Non-Gazetted )
g) Station/Place of last posting

2. Pay a) Basic Pay

b) Special Pay

c) Technical Pay

d) Personal Pay

e) Qualification Pay
f) Senior Post allowance
g) Any other Pay/allowance
reckonable for pension

Total

3 Date of birth D D M M Y Y Y Y

4. Date of entry into service D D M M Y Y Y Y

5. Date of retirement on account of Incapacitation D D M M Y Y Y Y

7. Address(s) of the beneficiary alongnwith contact No:

a. Present/Mailing (complete postal address):

b. Permanent:

c. Telephone No.: Mobile No.:

d. E-Mail (if any):

8. Bank Account title:

9. Name and city of National Bank of Pakistan Branch, nearest to the residence of beneficiary:

10. Bank Account No (s).

11. Period of EOL or period for which contributions to Benevolent and Group Insurance Funds was not
paid:
 PART-II

CERTIFICATION BY THE HEAD OF DEPARTMENT.

It is certified that:

1. The information contained in Part-I in respect of Mr./Miss/Mrs.

is correct according to our record.
2. The above named employee was neither Contingent Paid/Work Charged/Adhoc/Contract employee etc. nor a
deputationist from any Provincial/local government and was a regular contributor of FEB & GI Funds. Further
he/she was neither dismissed nor removed from services (in case of a deputationist from one Federal Government
department to another, the case will be prepared by his/her parent department).
3. The employee retired from service on account of incapacitation with 80% disability declared by the prescribed
Medical Authority under Rule 8 of FEB & GIF Rules, 1972.
4. The particulars of nominee(s) of Benevolent Grant and sum assured etc. of deceased employee
mentioned in Part-I above are correct and there is no other nominee(s) as per record of this office. In case,
particulars of nominee(s) given in Part-I found incorrect at later stage by any forum, our department will be
responsible for refund of sanctioned grant(s) to FEB & GIF.

5. The above claim is prepared for the first time and has not been sent previously from his/her parent department.

6. The above named employee was not uniformed employee of Armed forces at the time of incapacitation/
retirement.

Dated. Stamp and Signature

Head of the office

DEPARTMENTAL FORWARDING

Forwarded to Deputy Director/Incharge, Regional Board, Federal Employees Benevolent and Group Insurance
Funds, Islamabad/Karachi/Lahore.

F.No. Dated.

Stamp and Signature

Head of the Department
or authorized officer not below BS-20

PART-III
Visible and Attested Photocopies on A-4 size paper of the following documents shall be submitted with this
application form.
a) Annex “A”- Last pay certificate/computerized pay slip duly countersigned by head of department showing
personal No. allotted by the Accounts Office.
b) Annex “B”- First, second and last page of service Roll/book/PPO//statement of service in case of gazetted
employee.
c) Annex “C”- CNIC in respect of the aforesaid incapacitated employee. (Both sides of CNIC must be copied on
A-4 size paper)

d) Annex “D”- Notification/office order under which name of incapacitated employee was struck off the strength
from service.

e) Annex “E”- A copy of the Medical Board proceedings duly attested by the Head of Department. The Medical
Board must comprise of three Medical Officers, one of them shall be a specialist. The Medical Board
proceedings must record the case history as well as exact nature of disability (See Part IV).
f) Annex “F”- Nomination form of benevolent fund and group insurance.

h) Annex “G”- List of dependent family members i.e. wife/wives, natural son(s), father, mother, minor brothers
and unmarried/divorced/widowed sisters/daughters. The list should indicate name, CNIC No. relationship, age,
marital status, profession, monthly income, present mailing address and contact numbers.
i) Annex “H”- Envelope containing four copies of photographs duly attested in respect of the incapacitated
employee bearing the name of the person on the reverse of three photos and one on the face. In case of purdah
observing ladies, photographs will not be required, A certificate that she is Purdah observing lady must be
attached.
j) Annex “I”- Four signatures/right and left thumb impressions on separate sheets (four on each sheet) of
incapacitated employee duly attested by class-1 Gazetted Officer.
 PART IV
INVALIDATION CERTIFICATE FEDERAL EMPLOYEES
See CSR articles 442(d), (e), 443(a), (b) and (c) and 447.

1. Important Instructions:

(a) All columns must be typed.

(b) All columns must be filled. Those not applicable must be crossed.

(c) An individual shall not be considered removed from service until the Head of
Department has approved proceedings of the central Medical Board constituted by
Ministry of Health.

(d) Medical Board must comprise three members including one member as being a
Specialist pertaining to the disease for the invalidation of the employee .

Name S/o, D/o, W/o

Designation Office
Department Total Service
Age: Per Statement/documents per appearance
Identification marks

Head of Department of the Employee is personally responsible for accurate

information of this form.

(Left hand thumb impression/signatures duly attested)

Opinion : (A detailed statement of medical case and of the treatment adopted as per CSR 443(a).
If necessary attach documents).

Signature & Seal of

Medical Specialist.
 2. Opinion of the Medical Board:
In consequence of
We consider him/her (name) as being

(a) Completely and permanently incapacitated for further service of any kind.
(b) Completely and permanently incapacitated for service in the Department to
which he/she belongs.
(c) Incapacitated for service in the appointment which he now holds but we are of
the opinion that he/she is (or may after resting for
months be) fit for further service of less laborious
character than that which he/she has been doing.
(d) His/her degree of disability _ %age
(e) His/her incapacity does/does not appear to have been caused/aggravated or
accelerated by irregular or intemperate habits.

Dated: _ President
(Name, Signature & Seal)

Member Member
(Name, Signature & Seal) (Name, Signature & Seal)

APPROVED/NOT APPROVED

(For partial) disability See CSR article 447 (b). If a person is likely to improve after a
certain period he may be given long leave admissible to him instead of invaliding him out of
service.

Place
Dated

HEAD OF DEPARTMENT
(Name, Signature & Seal).

For further information/complaint, please visit our website i.e. www.febgif.gov.pk Ph.051-9252164
Federal Employees Benevolent &Note:
GroupPhotocopy
Insurance Funds
of thisBenevolent FundbeBuilding,Block
form can also used. A-1 Near Zero point,
Islamabad.
 NATIONAL HIGHWAY

List of Dependent Family Members of Mr/Mrs.

Sr Date of Marital Monthly

Name CNIC Relationship Profession
# Birth Status Income

Signature:_

Name:

Designation:

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
 NATIONAL HIGHWAY

Four Specimen Signatures / Thumb Impressions of Mr/Mrs. .

1. .

2. .

3. .

4. .

Attested
3 Medical Book of
i. Name of Employee ……………………………………..……………………….……………...

ii. Designation & Pay Scale ………………………………………….……………………….....

iii. Full Residential Address ……………………………………………………………….……..

……………………………………………………………………………………………….………

iv. Particulars of Dependent Family Members:

S# Name Relationship Age

(Y-M-D)

I declare that the information given is true and that the persons named
above are family – dependent upon me. I also hereby have given an
undertaking that my father or mother is not serving in any government
organization and wholly depend upon me.

Signature ………………………………………...……

Name……………………………………….……...

Designation……………………………………….

Page 10 of 19
3 Form of Nomination (See Rule –
Name and Designation of Employee …………………………………………………………………

………………………………………………………………………………………………………..……..

Service/Department ………………………………………………………………………………...….

I hereby nominate the person/persons mentioned below who is/are member/member

of my family as defined in Section-2 of the General Employee Benevolent Fund and
Group Insurance Act – 1969 (II of 1969) to receive the benevolent grant and the sum
assured and C.P Fund in the event of my death.
Part-I
(FOR WIFE / HUSBAND ONLY)
Relation Age % of Remarks
Name of Nominee/Nominees
ship (Y-M-D) Share

Part-II
(FOR MEMBERS OF FAMILY OTHER THAN WIFE / HUSBAND)
Relation Age % of Remarks
Name of Nominee/Nominees
ship (Y-M-D) Share

Certified that the Member/Members of family mentioned in Part-II reside with me and
are wholly dependent upon me.
The earlier nomination made by me may kindly be treated as “CANCELLED”

Dated…………………………… ...……………………………………….
Signature of the Employee
Witnesses:
……………………………..……..
i. Signature ………………………………. Name of Employee

…………………………………………….
Name & Designation
ii.
Signature……………………………….

………………………………………….. ………………………………………..
Name & Designation Signature & Seal of the Head of Office

Page 11 of 19
36 Nomination for Death-Cum-Retirement (TO BE FILLED IN
GRATUITY, PENSION / PAY & ALLOWANCES
(WHEN THE GOVERNMENT SERVANTS HAS A FAMILY & WISHES TO NOMINATE ONE MEMBER THEREOF)

I, hereby nominate the person mentioned below, who is a member of my family and
confer on him the right to receive any gratuity and the pension that may be sanctioned
by government and arrears of my pay and allowances due to me, in the event of my
death while in service and the right to receive gratuity, pension and pay and allowances
on my death which having become admissible to me on retirement may remain unpaid
at my death:-
Name, address &
relationship of the
Contingencies
person if any to
on the
whom the right
happening of
Relation conferred on the
Name & address (es) of the nominee(s) Age which the
ship nominee shall pass
nomination
in event of the
shall become
nominee
invalid
predeceasing the
Govt servant

Dated …………………………………………… at ……………………………………………………....

Witness’s signature
i. ……………………………………..

ii. …………………………………….. Signature of Govt Servant

To be filled in by the Head of Office in the case of non-gazetted Govt servants

Nomination by …………………………………………………………………………………..

Designation …………………………………………………………………………………….…

Office ………………………………………………………………………………………….……

Signature (Office Incharge) ……………………….....…………………………………...…..

Designation ………………………………………………………………………………….……

Dated…………………………………………………………………………………………..….

Caution: -This nomination can be cancelled at any time by sending a notice in writing to the
appropriate authority alongwith a fresh nomination.

Page 12 of 19
37 Nomination for Death-Cum-Retirement (TO BE FILLED IN

GRATUITY, PENSION / PAY & ALLOWANCES

(WHEN THE GOVERNMENT SERVANTS HAS A FAMILY & WISHES TO NOMINATE MORE THAN ONE MEMBER THEREOF)

I, hereby nominate the person mentioned below, who is a member of my family and
confer on them the right to receive to the extent specified below any gratuity and the
pension that my be sanctioned by government and arrears of pay and allowances due to
me, in the event of my death while in service and the right to receive gratuity, pension
and pay and allowance on my death which having become admissible to me on retirement
may remain unpaid at my death:-
Name, address &
Amount of relationship of
or share of Contingencies the person if any
pension/ on the to whom the
gratuity happening of right conferred
Name & address (es) of the Relation
Age and pay which the on the nominee
nominee(s) ship
and nomination shall pass in
allowances shall become event of the
payable to invalid nominee
each predeceasing the
Govt servant

Dated …………………………………………… at …………………………………………………….......

Witness’s signature

i. ……………………………………..

ii. ……………………………………..

Signature of Govt Servant

Note: This column should be filled in so as to cover the whole amount of the pension, gratuity and
pay and allowances.

(To be filled in by the Head Office in the case of non-gazetted Govt Servants)

Nomination by ………………………………………………………………………...……………

Designation ……………………………………………………………………………………….…

Office ……………………………………………………………………………………………….…

(Signature & Seal Office Incharge)

Caution:-This nomination can be cancelled at any time by sending a notice in writing to the
appropriate authority alongwith a fresh nomination

Page 13 of 19