Schedule LIII-Form No.378(New) O.C.S. (COMMUTATION OF PENSION) FORM 2 [See rules 5 (2), 9, 11, 12, 13, 19 and 22 read with F.D. Resolution No. 29826, dated the 9th July, 1992] FORM OF APPLICATION FOR COMMUTATION OF PENSION AFTER MEDICAL EXAMINATION BY AN APPLICANT REFERRED TO IN RULE 16 ( To be submitted in duplicate ) Space for photograph To The ................... ................... ................... (Here indicate the designation and full address of the Head Office). Subject:-Commutation of pension after medical examination Sir, I desire to commute a fraction of my pension in accordance with the provisions of the Orissa Civil Services (Commutation of pension) Rules, 1992. An attested copy of my photograph is pasted on the application and an un-attested copy is enclosed. The necessary particulars are furnished below : 1. Name (in Block letters) . 2. Father's name (and also husband's name in the case of a female Government servant). . 3. Designation . 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 (indicate the amount of provisional pension if full pension not authorised). . 9. *Fraction of pension proposed to be commuted . *The applicant should indicate the fraction of the amount of monthly pension (subject to a maximum of one-third thereof) which he desires to commute and not the amount in rupees. 2 10. Designation of the Accounts Officer who authorised the pension and the number and date of the Pension Payment Order. 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. 12. The amount of pension already commuted, if any. 13. Preference for nearest District Headquarters Hospital where medical examination is desired to take place. Place : Signature of the applicant Date : Postal address. **Score out which is not applicable. 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 authority from which pension is being drawn. 3 PART II ACKNOWLEDGEMENT Received from Shri ........................application in Part I of Form 2 for commutation of a fraction of pension after Medical Examination. Place : Signature of Head of Office Date : Authorised Authority 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 the particulars furnished by the applicant in Part-I have been verified and are correct and the applicant is eligible to get a fraction of his pension commuted after Medical Examination. 2. It is requested that Part-IV of form may be completed and returned to this Office as early as possible. Place : Signature of the Appointing Date : Authority/Authorised Authority 4 PART IV (To be completed by the Accounts Officer) 1. Name of the applicant . 2. Date of birth (by Christian era) . 3. Date of retirement . 4. Amount of pension including provisional pension, if final pension not authorised. . 5. Class of pension . 6 Amount of pension desired to be commuted. On the basis of Normal age Added years 1 year 2 years Rs. Rs. Rs. 7. (I) Sum payable if commutation becomes absolute before the applicant's next birthday, which fails on ....... (ii) Sum payable if commutation becomes absolute after the applicant's next birthday, which falls on ...... 8. The Head of Account to which commuted value is debitable. 9. No. of enclosures, if any. (See note abelow) .. Place : Signature and designation of the Accounts Officer Date : Countersigned Appointing Authority Full address. NOTE-The Accounts Officer should enclose with the form a copy of the report or statement of the applicant's case if the applicant has been granted invalid pension or has previously commuted a part of his pension or declined to accept commutation on the basis of an addition of years to actual age, or has been refused commutation on medical grounds.
