From

.
To
The Accountant General,
Chennai- 600 018
Through proper channel
Sir,
Sub: Submission of revised pension proposal as per G.O Ms.No.105 Fin (Paycell)
dept dated 07/02/06 Regarding
Ref:
1 Letter No.XI /V /574 from O/O The Accountant General (A & E). Tamilnadu,
Chennai
2 Admissibility report No. with Date PXI/V/C36-1175/450/05-06 dated 12/05
With reference to the letter cited, I am submitting the pension proposal with merger
benefits.
I am going to retire from service with effect from .
My date of birth is
. I request that necessary action may kindly be taken for the sanction of the
pension, Commutation amount, gratuity and family pension admissible to me from the date of
my retirement.
I desire to draw my pension from the Pay and Accounts Office (pension), College
Road, Chennai 600 006. I hereby declare that I have neither applied for nor received any
pension or gratuity in respect of my portion of the service qualifying for this pension and in
respect of which pension and gratuity are claimed herein nor shall I submit an application
hereafter without quoting a reference to this application and the orders may be passed
thereon.
I am governed by Rule 54 of the Tamilnadu Pension Rules 1976 and that the details of
my family already furnished by me in Form 03 are complete and up to date.
I enclose herewith in triplicate the following:
Form 5 (Part I & II)
Specimen signature
Pass port size joint photos
Particulars of height and identification marks
Left hand thumb and finger impressions
List of family members
Declaration
Requisition letter for extension of service
Nomination for family pension
My present address:

After retirement:

Chennai- 600 039

Dated: .

Yours Faithfully,

Signature of the Principal

FORM 5
Particulars to be obtained by the Head of Office from the Retiring Government
Servant ONE YEAR before the date of his Retirement
(G.O.Ms.No.989, Finance (B.G.III) Department, dated 10.9.86)
PART I
1.

Name

2.

(a) Date of Birth

(b) Date of retirement
(c) Designation at the time of retirement

3.

Two specimen signatures duly attested (to be

furnished in a separate sheet

: Enclosed

4.

*Three copies of the pass port size joint

photograph with wife or Wife (to be attested by
the Head of Office)

: Enclosed

5.

**Two slips showing the particulars of height and : Enclosed

personal identification marks duly attested

6.

Present address

:,

7.

***Address after retirement

:,

8.

Name of the Treasury

: Pension Pay Office,

College Road,
Chennai 600 006

9.

Details of the Family in Form 3

: Furnished

10.

Class of pension

:Retirement on superannuation

11.

Amount of pension authorised

: To be filled in by the A.Gs office

later

12.

Whether pension is proposed to be commuted

: Yes

13.

@@ If so, fraction of pension to be commuted.

: 33 1/3 %

Commutation value

= Rs.

13(a)

Date :
Place :

Signature
Designation
Department/Office

:
:
:

Two slips each bearing the left hand thumb and finger impressions duly attested by
the Head of Office may be furnished by a person who is not literate enough to sign his
name. If such a Government Servant on account of physical disability is unable to
give left hand thumb and finger impression he may give thumb and finger
impressions of the right hand. Where a Government Servant has lost both the hands,
he may give his the impressions. Impression should be duly attested, by the
competent authority.
*Two copies of passport size photo of self only need be furnished.
i.

If the Government servant is governed by rule 49 of the Tamilnadu Pension

Rules, 1978 and is unmarried or a widower/widow.
ii. If the Government Servant is governed by rule 50 of the Tamilnadu Pension
Rule, 1978.
iii. Where it is not possible for a Government Servant to submit a photo with wife
or Wife he or she may submit separate photographs. The photos shall be
attested by the Head of Office.
**Specify a few conspicuous marks, not less than two if possible.
***Any subsequent change of address should be notified to the Head of Office and
Audit officer.
@@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 note
the amount in rupees.

Signature of the Principal

FORM 5
PART II
1. Forwarded to the Accountant-General, Tamilnadu with the remarks that :i.

The particulars 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.9,150/2.

It is requested that further action to authorise the payment of the

amounts of commuted value of pension may be taken as in rule 15 of the
Tamilnadu (Commutation of Pension Rules).
3. The commuted value of pension is debitable to Head of Account.:
Govt.Account 2071 Pension and other retirement benefits
A slip containing 3 specimen signatures of .. is enclosed
A slip containing passport size photograph of is enclosed
A slip containing details of family members of is as under
Sl.No.

Name of the family

members

Relationship

Age

Married or
Unmarried

1.
2.
3.

Place: Chennai-600039
Date:

Signature of the Head of Office.

Specimen signature of

1.

2.

3.

/ Countersigned/

Place: Chennai-39
Date:

Signature of the Principal

PASSPORT SIZE JOINT PHOTOGRAPH WITH WIFE OF

Place : Chennai-39
Date :
Applicant

/Countersigned/

SIGNATURE OF THE PRINCIPAL

PARTICULARS OF HEIGHT AND IDENTIFICATION OF

1. Height

cm

2. Identification marks

: (i)
(ii)

Place: Chennai 39
Date:

Applicant
/ Countersigned/

Signature of the Principal

LEFT HAND THUMB AND FINGERS IMPRESSION OF:

Little Finger

Ring Finger

Middle Finger

Fore Finger

Thumb

Place: Chennai 39
Date:
Applicant
/ Attested /

Signature of the Principal

FORM 3

Details of Family
1. Name of the Government Servant

2. Designation
3. Date of birth

:
:

Details of Members of my family are as follows

Sl.No.

Name of the member of

family

Date of
birth

Relationship

Marital Status

1.
2.
3.

Place: Chennai 39
Date:
Applicant

/ Countersigned /

Signature of the Principal

Declaration of Consent for Recoveries

I, . hereby certify that I am willing to make good any loss caused to

Government by way of over-drawal of my pay, allowance or leave salary or other

admitted and obvious dues as a result of negligence or fraud, if any, on my pension.
I, .. hereby declare that I have neither applied for nor received any
pension or Gratuity in respect of any portion of the service qualifying for this pension
and in respect of which pension and Gratuity herein nor will I submit an application
hereafter without quoting a reference to this application and the order which may be
passed herein.
I, hereby agree for the recovery from my pension and Gratuity/
Family pension of any amount, which may be due and recoverable from me.
I, . hereby declare that no disciplinary action is pending against
me.

Place: Chennai-600 039

Date:
Applicant

/Countersigned/

Signature of the Principal

CALCULATION SHEET
Name:

10

Particulars

From

To

Total
Y

Grand Total
D

i) Length of Service Govt.

ii) EOL not Qualifying

for Pension

iii) Net Qualifying

service
iv) No. of Half Years of
Qualifying service
Lat Pay Drawn
Emoluments for the last month= B.Pay Rs-+DP =
Pension
AE x Qual. No. of half Years 66/ 66 x 1/2 = x 1/2 = Rs.

Amount of Death cum Retirement Gratuity

Pay last drawn:
= Basic Pay: Rs. .. + D.Pay Rs. + DA: Rs.. = Rs.
DCRG= Rs X 66/ 4= Rs.- restricted to Rs.3,50,000/
Amount of Family Pension:
30% of Pay Last drawn Rs. 28040/= Rs.
Enhanced equal to 50% of salary last drawn = Rs X X = Rs.

Amount of Commutation Pension:

331/3 % of Pension of Rs . X 10.46 X 12 = Rs.
---------------------------------------------------------------------------------------------------------------Date of retirement:
Date of first appointment
Date of Birth

SIGNATURE OF THE PRINCIPAL

Form 7
FORM FOR ASSESSING PENSION AND GRATUITY

11

Part I
1. Name of the Government Servant
2. Fathers Name
3. Date of Birth
4. Religion and Nationality
5. Permanent Residential Address

:
:
:
:
:, .

6. Present or last appointment

including name of establishment
(i) Substantive

(ii) Officiating
7. Date of beginning of service
8. Date of ending of service
9. (i) Total period of Military
service in which Pension/
Gratuity was sanctioned
(ii)Amount and nature of pension/
Gratuity received for the
Military service
10. Amount and nature of any Pension/
Gratuity received for previous civil
Service
11. The date on which action was
initiated to
(i) Obtain the No demand
Certificate from the
Department in charge of
building as provided in
Rule 58
(ii) Assess the service and
emoluments qualifying for
pension as provided in Rules
57&61
(iii) Assess the Government dues
other than the dues relating to
the allotment of Government
accomodation
12. Details of commission, imperfection or
deficiencies in the service book which has
been ignored

: Nil
:
:
: Nil
: Nil
: Nil

: Nil

: Nil

: Nil
: Nil

12

13. Length of qualifying service

Date of retirement
Date of appointment
14. Periods of non-qualifying service
(i) Interruption(s)

:
:

Total
15. Emoluments reckoning for Gratuity
16. Pay last drawn
17. Date on which the Government servant
applied for Pension in Form-3
18. Proposed Pension
19. Proposed/Death cum Retirement
Gratuity
20. Date from which Pension is to commence
21. Proposed amount of Provisional Pension
if departmental or judicial proceeding
is initiated against the Government
Servant before retirement
22. Details of Government dues referred to in
Rule 70 recoverable out of Gratuity
23. Whether nomination is made for
(i) Death cum Retirement Gratuity
(ii)Non-Contributory Family Pension if
applicable

: Nil

(ii) Extraordinary leave not qualifying

for pension

(iii)Period of suspension not treated as

qualifying
(iv) Any other service not treated as
qualifying

: Nil
: Nil

Y
M
D
:
0
01
16

: Pay:.. +DP ..+DA: ..

= Rs ./:B.Pay Rs+D.Pay Rs..
= Rs./:
: Rs. /: Rs.3,50,000/:

: Nil
: Nil
: Attached in the SR
: Nil

24. Whether Contributory Family Pension is

applied to the Govt. Servant and, if so,

13

(i) Emoluments reckoning for Family

Pension

: B.Pay Rs..+
D.Pay Rs.. = Rs./-

(ii) The amount of the Family Pension

becoming payable to the Wife of
Govt. Servant in the event of his
death after retirement
(iii) Complete and up to date details of
Family as given in Form 3
S.No

Name of the member

of the family

: Rs..
:

Relationship
with the Govt.
Servant

Age

Date of birth

Marital
status

1
2.
3.
25. Height
26. Identification marks

:
(i).

cms

(ii)
27. Place of payment of Pension/
Gratuity

: The Pay and accounts office for

pension, College Road,
Chennai 600 006

28. Head of Account to which Pension

and Gratuity are debitable

: Govt. Account 2071 pension and other

retirement benefits

Applicant
Place: Chennai- 39
Date:
Signature of the Principal

This is to certify that no disciplinary action is pending against

14

Signature of the Principal

15

FORM E
NOMINATION FOR FAMILY PENSION
I hereby nominate my ..
, ,
to receive my family pension in the event of my death.

Place: Chennai-39

Signature of the Government Servant

Date:

Witnesses to Signature

Name & Designation

1)

2)

Signature of Head of Office

16