Schedule LIII-Form No.376(New) O.C.S. (COMMUTATION OF PENSION) FORM 1 {See rules 5 (2), 6 (1), 11,12,13,14 and 15 read with F. D. Resolution No. 29826, dated the 9th July, 1992} 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 ..................... ..................... ..................... (here indicate the designation and full address of the Head of Office) 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 Orissa Civil Services (Commutation of Pension) rules, 1992. The necessary particulars are funished below : 1. Name (in Block letters) 2. Father's name (also husband's name in the Case of a female Government servant). 3. Designation at the time of retirement 4. Name of Office/Department in which Employed 5. Date of birth (by Christian Era) 6. Date of retirement 7. Class of pension on which retired 8. Amount of pension authorised [in case of final amount of pension has not been authorised, indicate the amount of provisional pension sanctioned under rule 65 if the Orissa Civil Services (Pension) Rules, 1992] 9. *Fraction of pension proposed to be committed. *The applicant should indicate the fraction of the amount of monthly pension (subject to maximum of one third thereof) which he desires to commute and not the amount in rupee. 10. Designation of the Accounts Officer, who authorised the pension and the No. and date of the Pension Payment Order, if issued. 11. Disbursing authority for payment of pension - (a) Treasury /Sub-Treasury/special Treasury (Name and complete address of the Treasury / Sub-Treasury/ Special Treasury to be indicated. (b) (i) Branch of the Nationalised Bank with complete postal address. (ii) Bank Account No. to which monthly pension is being credited each month. Place ........ Signature of the Applicant Date ....... Postal Address Note - The payment of commuted value of pension shall be made through the disbursing authority from which pension is being drawn. It is not open to an applicant to draw the commuted value of pension from a disbursing authority other than the disbursing authority from which pension is being drawn. ? Score out which is not applicable. PART II ACKNOWLEDGEMENT Received from Shri..................application in Part I of (name and former designation) Form I for the commutation of a fraction of pension without medical examination. Place ......... Signature of Head of Office/Authorised authority Note - This acknowledgement is to be signed, stamped and dated and is to be detached from Form and handed over to the applicant. If the form has been received by post, it has to be acknowledged on the same day and the acknowledgement sent under registered cover. PART II-A Forwarded to the ......................for needful. The receipt OF Part I of the Form has been acknowledged on ........... Signature of Head of Office PART III Forwarded to the Accountant General, Orissa ................ With the remarks that : (i) the particualars furnished by the applicant in Part I have been verified and are correct. (ii) the applicant is eligible to get a fraction of his pension commuted without medical examination. (iii) The commuted value of pension determined with reference to the Table applicable at present comes to Rs......... (iv) The amount of residuary pension after commutation will be Rs....... 2. It is requested that further action to authorise the payment of the amount of commuted value of pension may be taken as per the Orissa Civil Services (Commutation of Pension) Rules, 1992. 3. The receipt of Part I of the Form has been acknowledged in Part II which has been forwarded separately to the application ................ 4. The commuted value of pension is debitable yo 'Head of Account ........ Place ......... Signature of the Appointing Authority Date .......... OGP (Forms) 264-2,00,000-22.3.2000
