THROUGH PROPER CHANNEL To The Vice-Chancellor CSK HPKV, Palampur (HP). Subject: Application for sanction of Pension. Sir, I beg to say that I shall retire from University service in ________________ under rule _____________ of University Pension Rules as notified vide Comptroller, HPKV, Palampur Notification No. 1-120/88(A/Cs)/-1-81 dated 1.1.1997, I have opted to be governed by the HPKV Pension Scheme in terms of the notification which has been accepted by the Competent Authority. I therefore, requested your goodself to kindly grant pension/family pension/gratuity/death gratuity in my favour. I hereby declare that I have neither applied for, nor received, any pension or gratuity in respect of any pension or gratuity in respect of any position of the service qualifying for this pension and in respect of which pension and/or gratuity is claimed, herein nor shall submit an application thereafter without quoting a reference to this application and the order which may passed hereon. I enclose herewith:i) Two slips bearing left hand/right hand thumb and fingers impressions (duly attested). ii) Two slips bearing specimen signature duly attested. iii) Four joint passport size photographs duly attested. iv) Option for medical facility. v) _____________________________________________ Encls: As above. Dated: _____________ Yours faithfully, Signature:_____________________ Name:________________________ Address:______________________ FORM: KVV-10/7 CHAUDHARY SARWAN KUMAR H. P. KRISHI VISHVAVIDYALAYA (See Rule 10.23 of Part-I of the Account Mannual) Form of Assessing Pension and Gratuity PART - I 1. Name of the University employee : 2. Father's Name (and also husband's name in the case of female University employee) : 3. Date of birth (by Christian era) : 4. Religion : 5. Permanent residential address showing village, town, district and state : 6. Present or last appointment including name of establishment i) Substantive ii) Officiating, If any : 7. Date of beginning of Service : 8. Date of ending of service : 9. i) Total period of military service for which pension or gratuity was sanctioned. ii)Amount and nature of any pension/ gratuity received for the military service : 10. Amount and nature of any pension/gratuity received for previous civil service. : 11. Government/ CSKHPKV, Palampur under which service has been rendered in order of employment. : Years Months Days 12. Class of pension applicable : 13. The date of which action initiated to .... i) obtain the 'No demand certificate' from the Estate Organization. ii) assess the service and emoluments qualifying for pension. iii) assess the University dues other than the dues relating to the allotment of University accommodation. : 14. Details of omissions, imperfections or deficiencies in the service book which have been ignored : 15. Total length of qualifying service (for the purpose of adding towards broken periods, a month is reckoned as thirty days). : 16. Periods of non-qualifying service ...... i) Interruption in service condoned ii) Extraordinary leave not qualifying for pension iii) Pension of suspension not treated as qualifying iv) Any other service not treated as qualifying : From: To: Total:................. (Contd. .2) 17. Emoluments reckoning for gratuity : 18. Average emoluments : Post held From To Pay Personal pay or special pay Average Emoluments 19. Date on which particulars have been obtained from the University employee (To be obtained eight months before the date of retirement of the University employee in Form KVV 10/8 : 20. i) Proposed pension ii) Proposed graded relief : 21. Proposed death-cum-retirement gratuity : 22. Date from which pension is to commence : 23. Proposed amount of provisional pension. (If departmental or Judicial proceedings are instituted against the University employee before retirement) : *(i) In a case where the last ten months include some period not to be reckoned for calculating average emoluments an equal period backward has to be taken for calculating average emoluments. (ii) The calculation of average emoluments should be based on actual number of days contained in each month. 24. Details of Government dues recoverable out of gratuity:- i) License fee for the allotment of University accommodation. ii) Other dues : 25. Whether nomination made for ......... i) Death-cum-retirement gratuity. ii) Family Pension 1950, if applicable. : 26. Whether family pension 1964 applied to the University employee, and if so- i) emoluments reckoning for the family pension ii) the amount of the family pension becoming payable to the family of the Govt. Servant, if death takes place after retirement:a) before attaining the age of 65 years, or b) after attaining the age of 65 years c) other University dues as mentioned in item 15(iii) of Part-I d) Total of (a), (b) and (c) : Rs._______________________________ Rs._______________________________ Rs._______________________________ Rs._______________________________ Place:______________________ Dated, the:__________________ Signature of Head of Office PART - II Section - I Account Enfacement: 1. Total Period of qualifying service which ahs been accepted for :i) Death-cum-retirement gratuity ii) Family Pesion : 2. Net amount of gratuity after adjusting University dues : 3. Amount and the period of tenability of Family : Amount Period of tenability Pension. If death took place: Rs. From To i) before seven years service. ii) After seven years service. 4. Date from which Family Pension is admissible : 5. Head of Account to which death-cumretirement gratuity and family pension are chargeable. : Section - II 1. Name of the deceased University employee : 2. Date of death of the University employee : 3. Date on which the Pension papers received by the Comptroller : 4. Amount of family pension authorised : 5. Amount of gratuity authorised : 6. Date of commencement of family pension : 7. Date on which payment of family pension and gratuity authorised. : 8. Amount recoverable from gratuity : 9. Amount of gratuity held over pending receipt of 'No demand Certificate'. : Place:___________________________ Comptroller Dated, the: ______________________ FORM: KVV-10/8 CHAUDHARY SARWAN KUMAR H. P. KRISHI VISHVAVIDYALAYA (See Rule 10.25 of Part-I of the Account Mannual) Particulars to be obtained by the Head of Department from the retiring University employee eight months before the date of his/her retirement. 1. Name : 2. (a) Date of birth (b) Date of retirement : : 3. Two specimen signature dully attested (to be furnished in separates sheet) by the Head of office/department. : 4. Four (4) copies of passport size joint photograph with wife or husband (to be attested by the Head of office/unit). : 5. Two copies showing the particular of Height & personal identification marks duly attested by 'A' Grade University employee. : 6. Present Address : 7. Address after retirement : 8. Details of family in from as under : 1 2 3 4 5 6 Sr. No. Name of the members of the family Date of Birth Relationship with the employee Initial of Head of office Remarks 1 2 3 4 5 6 Date:____________________ Place:____________________ Signature:___________________ Name:______________________ Designation:_________________ Specimen signatures in respect of Dr./Sh./Smt/ __________________________ (Designation) ______________________________ of the Office/Department of ________________________________________________________________. Name Specimen Signature 1. 1. 2. 2. 3. 3. Attested Attested Statement showing left/right hand thumb and fingers impression of Dr./Sh./ Smt. ________________________________ designation ______________________ Office/Department of ________________________________________________ Left Hand Thumb & Fingers Impression Right Hand Thumb & Fingers Impression 1. Little finger 2. Right finger 3. Middle finger 4. Fore finger 5. Thumb Attested Attested HEIGHT & IDENTIFICATION MARKS Height & Identification Marks in respect of Dr./ Sh./ Smt. ___________________ _____________ designation ____________________ Office/Department of 1. Height : 2. Identification Marks 1. 2. : : : Signature of the Head of Office HEIGHT & IDENTIFICATION MARKS Height & Identification Marks in respect of Dr./ Sh./ Smt. ___________________ _____________ designation ____________________ Office/Department of 1. Height : 2. Identification Marks 1. 2. : : : Signature of the Head of Office FORM OF APPLICATION FOR COMMUTATION OF PENSION WITHOUT MEDICAL EXAMINATION. To Subject: Commutation of pension with Medical Examination. Sir, I desire to commuted fraction of my pension as indicated below in accordance with provision of the Central Civil Services (Commutation of Pension) Rules, 1996. The necessary particulars are furnished below:- 1. Name in Block letters : 2. Father's Name (and also Husband's Name in the case of female Govt. Servant) : 3. Date of Birth (by Christian era) : 4. Date of retirement on superannuation : 5. Designation of the post held at the time of superannuation and the name of the Department/Office : 6. Name of the Branch of State Bank of India located nearer to his/her home and A/c No. from which pension is required to be drawn. : 7. Designation of the Accounts Officer and the number and date of the PPO, if issued : 8. Fraction of superannuation pension proposed to be commuted : Dated:___________________ Signature:_______________________ Place:____________________ Name:___________________________ Postal Address after Retirement: ________________________________ ________________________________ ________________________________ OPTION I, _____________________________________________________ Designation _________________________________________ Department of _________________________________________________________, hereby opt for fixed medical reimbursement facility/open medical reimbursement facility as applicable to the pensioners/family pensioners of the CSK Himachal Pradesh Krishi Vishvavidyalaya. Signature of the retiring Govt. Employee/Office/Pensioners Name:___________________________ Designation:______________________ Dated:___________________ Countersigned Head of Department/Controlling Officer DETAILS OF DEPENDENTS FAMILY MEMBERS 1 2 3 4 Sr. No. Name of the members of the family Date of Birth/Age Relationship with the employee 1 2 3 4 5 6 The above family members are wholly dependent upon me. Date:____________________ Place:____________________ Signature of the retiring employee Name:______________________ Designation:_________________ Countersignature Head of Department/Office TO WHOM IT MAY CONCERN Certified that there is not temporary Contingent/Personal Advance lying pending for adjustment/settlement against Dr./Sh./Smt. _______________ ______________ Designation _____________________ and further added that there is no audit para/ requisition or recovery outstanding included in the Aduit/ Inspection Report of AG HP/Examiner, Local Audit who is retiring on attaining the age of superannuation of _______________________________ . Date:____________________ Place:____________________ Signature of HOD/Office TO WHOM IT MAY CONCERN Certified that there is not temporary Contingent/Personal Advance lying pending for adjustment/settlement against Dr./Sh./Smt. _______________ ______________ Designation _____________________ and further added that there is no audit para/ requisition or recovery outstanding included in the Aduit/ Inspection Report of AG HP/Examiner, Local Audit who is retiring on attaining the age of superannuation of _______________________________ . Date:____________________ Place:____________________ Signature of HOD/Office FINAL NO DUE CERTIFICATE As per the informations received from various Units/Offices/Stations of Chaudhary Sarwan Kumar Himachal Pradesh Krishi Vishvavidyalaya, there is noting due against Dr./Sh./Smt. ____________________________________ Designation _____________________ retiring on attaining the age of superannuation of _______________________________ . Date:____________________ Signature of HOD FINAL NO DUE CERTIFICATE As per the informations received from various Units/Offices/Stations of Chaudhary Sarwan Kumar Himachal Pradesh Krishi Vishvavidyalaya, there is noting due against Dr./Sh./Smt. ____________________________________ Designation _____________________ retiring on attaining the age of superannuation of _______________________________ . Date:____________________ Signature of HOD FINAL NO DUE CERTIFICATE As per the informations received from various Units/Offices/Stations of Chaudhary Sarwan Kumar Himachal Pradesh Krishi Vishvavidyalaya, there is noting due against Dr./Sh./Smt. ____________________________________ Designation _____________________ retiring on attaining the age of superannuation of _______________________________ . Date:____________________ Signature of HOD Service Verification certificate in respect of Dr./Sh./Smt. ___________________ Sr. No From To Service book entry page No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Date:____________________ Place:____________________ Signature of HOD/Controlling Officer FOUR (4) COPIES OF PASSPORT SIZE JOINT PHOTOGRAPH WITH WIFE OR HUSBAND (TO BE ATTESTED BY THE HEAD OF OFFICE/UNIT). Name : ____________________________________________________ 1 2 Signature Signature 3 4 Signature Signature
