PEN- 11

UCO BANK

APPLICATION FOR THE FAMILY PENSION ON THE DEATH OF

PENSIONER/EMPLOYEE/RETIREE

1. Name of the applicant :

i) Widow/ Widower :

ii) Guardian ( if the deceased person is :

Survived by minor child or minor children)

2. Name, relationship and date of birth of surviving widow/ widower

And children of the deceased employee/pensioner
Sl Name Relationship with Date of birth in
No deceased pensioner children era
1.

2.

3.
______________________________________________________________________________

3. Name of deceased : 4. PFM No:

5. Date of death of the

Employee/retiree/pensioner :

6. Office/Department ( in which the deceased :

Employee/pensioner served last

7. If the applicant is guardian date of :

Birth of minor and relationship with
The deceased employee/pensioner

8. If the applicant is employed give particulars :

9. Full address of the applicant :

10. Branch for payment of family pension :

With Code
I undertake to repay/authorize you to recover from the pension/family pension/
Commutation payable to me on the death of the above employee/retiree/pensioner any
amount that may be due from him/her to the Bank.

Date…………………… ……………………………………
( Signature or left/right thumb
Impression of the applicant )

Attested by Branch head :

…………………………………….
( Signature with seal)
Name in Full:
Full address:
Of the attesting authority

UCO BANK DD Block Sector-1

 Pension Cell Salt Lake
Personnel Services Deptt. Kolkata-700064

DESCRIPTIVE ROLL OF THE APPLICANT FOR FAMILY PENSION

Photo

1. Name : _________________________________________________

2. Widow/widower/son/daughter : _________________________________________________
Mother of late

3. Date of birth/ Age : _________________________________________________

4. Height : _________________________________________________

5. Prominent Identification marks : 1) _______________________________________________

On the hand, face, etc.
( Specify at least two conspicuous marks) 2) ________________________________________________

6. Left/ Right hand thumb : __________________________________________________

Impression

7. Specimen Signature : ___________________________________________________

____________________________________________________
8. Address in Full : ____________________________________________________
___________________________________________________

Attested by Branch head

Signature with seal :

Name in full :

Full Address :

UCO BANK DD Block Sector-1

Pension Cell Salt Lake
Personnel Services Deptt. Kolkata-700064
Ref. No. PER: PEN : 2012-13

The Branch Manager,

UCO Bank,

………………………………… Branch(………………….)

Sub : Settlement of Family Pension in favour of ………………………………………..

widow/widower/ son/daughter of Late…………………………………PFM no……………..
Expired on………….

In order to settle the above mentioned family pension the following papers/documents are
required
To be submitted to your Zonal Office for onward transmission to us:

(1) Family Pension application (PEN 11) in three sets ( enclosed) duly filled in and attested
by the In-charge of the Branch after keeping one set for your Branch one set for Zonal
Office &one set as personnel copy as personnel copy of the Family Pensioner.

(2) A duly attested copy of the Death Certificate of ………………………………………. Issued by

the competent Authorities such as the Corporation / Municipality/ Panchayat Authorities
concerned. If the Death Certificate is issued in vernacular, an English version of it is to be
sent along with it. If the name of the deceased mentioned in the Death Certificate differs
from that in the records of the bank, you must certify that the deceased person as per the
Death Certificate and the person as per records of the bank are one and the same person.

(3) Two copies of descriptive rolls / Identification marks of …………………………..

duly attested.

(4) Salary particulars ( revised, if applicable) for the last ten months i.e. for ten months
immediately prior to death of the employee, duly attested.

(5) A certificate of No Dues of the Employee to the Bank regarding outstanding loans duly
certified.

(6) A copy of the latest Family Declaration Form submitted by the deceased employee while
he/she was in service, duly attested.

(7) Latest two passport size photographs of ………………………………………… duly attested.

(8) Two copies of Birth Certificate issued by the Corporation/Municipal/Panchayat Authorities or

two copies of School Final or Higher Secondary Examination Certificate, each duly attested
by the In-charge of the Branch, in respect of each of the children of the deceased
employee, who may be eligible for family pension, as proof of his/ her date of birth.

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(9) An Affidavit duly affirmed by all the legal heirs of Late………………………………………

( including)
Married daughter) before a First Class Magistrate/ Notary Public on a non-judicial stamp
paper as per the pro forma given in Form No. 1 enclosed. If the affidavit is affirmed before a
Notary Public, the notarial stamp of requisite value should be affixed on the affidavit. The
original affidavit should be sent to us retaining a copy of it with you.
(10) An Agreement, as per Form No. II enclosed, executed by the widow/widower and other
legal heirs of Late………………………………… ( including married daughter) on a non-judicial
stamp paper not below Rs. 50/- ( Rupees Fifty only). The original agreement should be sent
to us retaining a copy of it with you.

(11) Whether the deceased ex-employee was ex-serviceman prior to his joining the bank. If
yes, the applicant for family pension is to submit an option to draw military family pension or
bank family pension as per the pro forma enclosed.

(12) Declaration in the form of an affidavit stating that monthly income of the applicant from
all sources do not exceed Rs. 3500/- and confirmation of unmarried ( in case of daughter)

(13) Confirmation by the branch regarding payment of pension/ revised pension/ family pension
to the pensioner / family pensioner till the date of death.

(14) Others:

On receipt of the above papers/ documents we shall revert to the matter.

Chief Officer
Pension

Encl. As stated above

1
AFFIDAVIT

(1)Shri/Smt…………………………………….aged……….(relation)________________ of
Late________________________________________
(2)Shri/Smt…………………………………….aged……….(relation)________________ of
Late________________________________________
(3)Shri/Smt…………………………………….aged……….(relation)________________ of
Late________________________________________( Names of all the legal heirs will appear above) all
by creed______________ by Nationality__________ by occupation__________________ do hereby
solemnly affirm and declare as follows:

1.That we are the permanent inhabitant of the above mentioned address and citizen of India.

2. That Shri/Smt_____________________ now deceased was the ________________ (relation) of the above
declarants who died intestate on __________ at our above mentioned address.

3. That at the time of demise of Shri/Smt____________ he/she was leaving behind him/her legal heirs as follows:

Sl. No._____________Name______________Address_____________Age______ relation(s)

(1)
(2).
(3)
(4)
4. That there is no other legal heirs of said deceased Late______________ except above referred names.
5. That our deceased _____________(relation) Late_________________ was the employee of UCO Bank and
Late________________ was superannuated from his service on____________
6. That the date of commencement of Normal Pension of Late__________ was on___________

7. That during his/her lifetime he/she had been sanctioned/not sanctioned his/her pensionary benefits up
to__________ As such, the arrears of pensions pensions from________ to _______is lying with authority in
his/her name only, which is inherited by his/her legal heirs and successors.

8. That we further declare that we have no objection if the competent authority will make payment of the above
said arrears of Pension of Late___________to our ____________(relations) Shri/Smt_____________ being the
applicant for the Family Pensioner.

That the above statements are true to the best of our knowledge and belief and we sign this affidavit on to-day at
Court premises.

1.
2.
3.
4.
( ALL THE LEGAL HEIRS SHOULD SIGN HERE)

Signature of the deponents identified by me.

FORM NO. II

( TO BE STAMPED AS AN AGREEMENT )

UCO BANK
ADDRESS______________________________

Dear Sirs,
 In consideration of your agreeing at my/our request and on the declaration made by me/us
to pay Shri / Smt.__________________________________ ( Claimant) the pensionary
benefits payable to Shri / Smt._____________________________ since deceased
without production of legal representation to the estate of said deceased, I / We
________________________________________________________________________
( Names of all legal heirs to be mentioned )
do hereby jointly and severally indemnify and agree at all times to keep indemnified you
from and against all claims that may preferred against you and all actions, proceedings,
claims and demands which may be brought or made against you by any person or persons
whomsoever in respect of the said pensionary benefits or any portion thereof and against
all losses, damages, costs, charges and expenses that you may incur or pay in
consequence of your paying the said persionary benefits to the claimant without
production of legal representation from a competent court of law.

Yours faithfully

1. __________________________________

( Claiment & 2. __________________________________

other legal heirs )
3. ___________________________________

Note:
Please strike out whichever is not applicable.

UCO BANK DD Block Sector-1

Pension Cell Salt Lake
Personnel Services Deptt. Kolkata-700064

To
Chief Officer ( pension)
UCO Bank, Pension Cell,
 Personnel Services Department
Head Office -2
3&4 DD Block, Sector-1
Salt Lake, Kolkata- 700064

Dear Sir

Sub: Exercise of option to draw * Military family/*bank family pension

I, Shri/Smt ……………………………………………………………………. , am the *widow/*son/daughter

of
Late…………………………………………………………… (PFM No……………). My deceased *husband /
Father, at the time of joining UCO Bank, was an ex-serviceman. I am therefore entitled to bank
family pension payable in terms of UCO Bank ( Employees’) Pension Regulations, 1995. I am
also entitled to military family pension. However, I Understand that in terms of the existing
Central Civil Services ( Pension) Rules, I am eligible to draw military family pension provided I do
not draw bank family pension.

I, therefore, hereby exercise my irrevocable option to-

a) draw bank family pension payable as per the provisions of UCO Bank ( Employees’)
pension Regulations,1995, forgoing military family pension.

Or

b) draw military family pension forgoing bank family pension payable as per the provisions
of UCO Bank ( Employees’) Pension Regulations, 1995.
(please tick ( ) only one option, either (a) or (b) given above, and strike out the other).

Please take necessary action to sanction/ not sanction bank family pension in terms of the
provisions of UCO Bank ( Employees’) Pension Regulations, 1995, accordingly.

(*Delete whichever is/are not applicable)

My address for communication is as under:-

Yours Faithfully

Date :

Place:
Attested by Branch head:

( Signature with seal)

Name & Full Address: