New Pension Form

COMBINED APPLICATION FORM FOR GENERAL
PROVIDENT FUND FINAL CLOSURE AND PENSION

PART-I
FOR RETIREMENT / REVISION CASES ONLY
(To be sent in Duplicate)
1. Name of the Government

Employee (IN CAPITAL LETTERS) :
2. Father’s Name / Husband’s
Name in the case of Female
Government Employee :
3. Designation with Selection
Grade / Special Grade :
4. Religion :
5. P.P.O. No. allotted by A.G’s.

Office. [Applicable only for
Revision Cases] :
6. G.P.F. No. with Departmental

Suffix. :
7. Date of Birth
8. Date of Joining
9. Date of Retirement
10. Present Residential Address

with PIN Code :
MOBILE No. :
11. Residential Address after

Retirement with PIN Code :
12. Place of Payment of Pension :

(a) Pension Pay Office
(b) District Treasury
(c) Sub-Treasury
13. Whether the Pension is Yes No

proposed to be commuted.
(Tick in appropriate place)? :
If Yes, fraction proposed to be

commuted : Fraction :
2
14. Are you in receipt of Military
Pension? : Yes No
15. If Yes, P.P.O.No. and Treasury P.P.O.No.

from which it is drawn may be PPO/District
furnished. Treasury/
Sub-Treasury
16. If you are in receipt of Military :
Pension, state whether you opt
for Military Family Pension or
Civil Family Pension. (Option
once exercised is final.)
17. List of Family Members :

including Wife / Husband.
Whether
Sl. Name (s) Marital Date of Handicapped/
No. Relationship Status Birth Mentally
Retarded.
* Medical Certificate to be enclosed.

18. Name of Guardian in case of :
mentally retarded children.
DECLARATIONS
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 are claimed herein nor
shall I submit an application hereafter without quoting a reference to this
application and the orders which may be passed thereon.
I do hereby declare to refund the pension or gratuity authorized by the

Accountant General, Chennai, if afterwards found to be in excess of the
amount to which I am entitled under the Rules.
I hereby certify to make good any loss caused to the Government by

way of any overdrawal of pay, allowances, leave salary or other admitted
obvious dues as a result of negligence or fraud on my part in service in the
department in a lumpsum or in suitable installments from my pension.
Place :
Date :
Signature of
Government
Employee with Date.

3
PART-II
TO BE FILLED IN BY THE DEPARTMENTAL OFFICER
1. A.G’s Office Reference No. in
which the proposals were
returned with objections earlier. :
2. Date of Beginning of Service. :
3. Date of Ending of Service. :
4. Gross Qualifying Service. :
5. Non-Qualifying Service. :
6. Additional Qualifying Service :

under Rule 27 / Due to
Volunta ry Retirement /
Contingent Service / Military
Service.
7. Net Qualifying Service. :
8. Total Period of Military Service :

and Military Pension / Gratuity
received. (Details of remittance
to be furnished separately).
9. Scale of Pay :
10. Pay Last Drawn (Special Pay, :

Personal Pay drawn if any to be
shown separately)
11. Class of Pension applicable :
12. Whether any charges are

pending against the Government :
Employee? If so, furnish the
details thereof.
13. Office served in the last three :

years.
14. a. Drawing Officer for G.P.F. :

with Full Postal Address and
PIN Code.
b. Phone No. of the Office with
STD Code.
c. e_mail ID / FAX :
4
15. Treasury / PAO for G.P.F. :
16. a. Drawing Officer for D.C.R.G. :

PIN Code.
b. Phone No. of the Office with :

STD Code.
c. e_mail ID / FAX
:
17. Treasury / PAO for D.C.R.G. :
18. Particulars of Last G.P.F. :

Deduction [Last 12 Months
Details].
Pay GPF Recov Total Date Sub- Voucher
for Sub- ery Amount & Account No.
Mont Scripion / of Cr. Place of
h Refun Schedul of Account
d e. Payme
nt
(1) (2) (3) (4) (5) (6) (7)
19. Details of Temporary Advance / :

Part Final Withdrawal
sanctioned in the last 12 months
(If no debit is drawn in last 12
months, the details of last debit
drawn should be specified.
Date of
Month Amount Voucher No.
Payment
(1) (2) (3) (4)
CERTIFICATE
It is certified that:
1. All the particulars furnished above have been fully verified with
reference to office records and are found correct.
2. Advance / withdrawal from GPF was granted during the last 12
months as detailed in Column 18 above.
3. No Charges are pending / Charges are pending against the
individual. (Details furnished separately)@
4. Provisional Pension not paid / Provisional Pension paid (Details
furnished separately) @
5. Conditions laid down in Rule 11(2) and Rule 11(3) of the Tamil
Nadu Pension Rules, 1978 have been satisfied and the same has
been recorded in Service Book.
@ Strike out whichever is not applicable.

5
CHECK LIST / LIST OF ENCLOSURES
1. Service Book(s). [No. of Volumes] : [Enclosed / Not Enclosed]

2. Recent Joint Passport size Photo :
with Spouse, Specimen Signature
/ left hand thumb impression (in
the case of illiterate) and
Descriptive Roll of the
Government Employee, all in
triplicate, duly attested [furnished
in the Annexure].
3. Sanction order in respect of :

Non-Government Aided Educational
Institution cases and
Missing Employee.
4. In case of Teachers, :
Non-Employment/Re-employment
Certificate.
5. Copy of First Information Report :

in respect of Missing Employee.
6. Nomination for General Provident :

Fund (GPF).
7. Nomination for Death cum :

Retirement Gratuity (DCRG).
8. Nomination for Life Time Arrears :

of Pension
9. Nomination for Commutation of :

Pension (in duplicate).
10. Medical Certificate in original in :

Form 23 as prescribed in Rule 36
of TNPR for invalidation cases
issued by Medical Board.
11. Certificate of Medical Opinion of :

the Doctors for admitting
Commuted Value of Pension in
the cases of Invalidation and
Compulsory Retirement cases.
12. Ratification Order of Government :

for waiving any shortfall in notice
period due to sanction of
Extraordinary Leave with /
without Medical Certificate (in
respect of Voluntary Retirement
cases).
13. Military Verification Certificate. :
6
14. Copy of the Chalan for refund of :
Gratuity received with Interest for
Military Service.
15. Copy of Proceedings issued in the :

case of Compulsory Retirement /
Voluntary Retirement /
Invalidation cases.
16. Copy of Government Order :

imposing cut in Pension issued on
completion of Disciplinary
Proceedings / Dropping the
Charges.
17. Copy of Adoption Deed, in case of :

adopted children.
18. Copy of Medical Certificate in the :

case of Mentally Retarded
Children / Handicapped Children.
Place :
Date :
Signature of the Head of Office
/ Department with Seal.
INSTRUCTIONS
1. Please send the application in DUPLICATE.
2. Please fill up all columns in capital letters.
3. Incomplete application will not be processed.
4. Annual Account Statement of GPF need not be sent.
5. Last Fund deduction particulars mean deduction to GPF

before stopping recovery.
6. For arriving at the Commuted value of Pension, dated

signature of the Government servant in Part I is compulsory.
7
ANNEXURE
(To be sent in Triplicate)
1. Joint Passport size Photo of the :

Government Employee with
spouse. (Name of the Government
servant and spouse should be
written).
Name of Government Employee :
Name of the Spouse :
Counter Signature of the Head of

Office
with Seal.
2. Specimen Signature / Left Hand : 1.

Thumb impression in case of
illiterate. 2.
3.
3. Descriptive Roll of Government : 1.

Employee. [Personal Marks of
Identification]. 2.
3.
8
NOMINATION FOR GENERAL PROVIDENT FUND

[ FOR USE BY SUBSCRIBERS HAVING FAMILY ]
GENERAL PROVIDENT FUND ACCOUNT NUMBER:
I, ……………………………………………………………………………….………… , hereby
nominate the person(s) mentioned below who is/are member(s) of my family as defined
in rule 2 of the General Provident Fund (Tamil Nadu) Rules, to receive the amount
that may stand to my credit in the fund as indicated below, in the event of my death
before that amount has become payable or having become payable has not been paid.
Name and full address of Relationship Age of the Share payable Contingencies on the Name, address and relationship
the nominee(s). with nominee to each happening of which the of the person/persons if any, to
Subscriber nominee nomination shall become whom the right of nominee shall
invalid. pass in the event of his/her
predeceasing the subscriber.
(1) (2) (3) (4) (5) (6)
Place :
Date : Signature of the Subscriber.
Signature of two witnesses with Name and Address:
1.
2.
-/ Countersigned /-
Signature of Head of Office.
Office Address:
9

[ FOR USE BY SUBSCRIBERS HAVING NO FAMILY ]
I, ……………………………………………………………………………….………… , having
no family as defined in rule 2 of the General Provident Fund (Tamil Nadu) Rules hereby
nominate the person/persons mentioned below to receive the amount that may
stand to my credit in the fund as indicated below, in the event of my death before that
amount has become payable or having become
payable has not been paid.
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
10
NOMINATION FOR COMMUTATION OF PENSION
I, ………………………………………………………… (Name of the Pensioner in Capital

Letters), hereby nominate the person / persons named below under Rule 12 of Tamil
Nadu Civil Pensions (Commutation) Rules, 1944.
Name and full Relationship Date of Name and address of Relationship Date Contingency on
address of the with Birth/ other nominee in with of happening of which
nominee(s). Pensioner Age case the nominee pensioner Birth/ nomination shall
under coulumn(1) Age become invalid
predeceases the
pensioner.
(1) (2) (3) (4) (5) (6)
NOTE: If nominee / alternate nominee is minor, furnish the name and address of person who may
receive the arrears of commutation of pension.
Place :
1.
2.
-/ Countersigned /-
Office Address:
11
NOMINATION FOR LIFE TIME ARREARS OF PENSION

Nadu Pension Rules, 1978.
predeceases the
pensioner.
(1) (2) (3) (4) (5) (6)
receive the arrears of pension.
Place :
1.
2.
-/ Countersigned /-
Office Address:
12
NOMINATION FOR RETIREMENT / DEATH GRATUITY
When the Government servant has a family and wishes to nominate one person or more
than one persons, thereof.
I, ……………………………………………………………………………….………… , hereby
nominate the person/persons mentioned below who is/are member(s) of my family, and
confer on him/them the right to receive, to the extent specified below, any gratuity, the
payment of which may be authorised by the Government of Tamil Nadu in the event of
my death while in service and the right to receive on my death, to the extent specified
below, any gratuity which having become admissible to me on retirement may remain
unpaid at my death.
Original Nominee(s) Alternative Nominee (s)
Name and full address of Relationship Age Amount Name, address relationship and age of Amount
the nominee(s). with or Share the person or persons, if any, to whom of share
the of the right conferred on the nominee of
Government Gratuity shall pass in the event of the nominee gratuity
Servant payable pre-deceasing the Government servant payable
to each or the nominee dying after the death of to each
the Government servant but before
receiving payment of gratuity
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
Note: (i) The Government Employee shall draw lines across the blank space below the last entry to prevent
the insertion of any name after he has signed.
(ii) Strike out which is not applicable.
(iii) If the Original Nominee(s)/Alternate Nominee(s) is/are minor, furnish the name and address of the
person with relationship to the Government
Employee to receive the amount.
* This column should be filled in so as to receive the amount.
** The amount / share of the gratuity shown in this column should cover the
whole amount / share payable to the original nominee(s).
13
When the Government servant has no family and wishes to nominate one person or
more than one persons, thereof.
I, ……………………………………………………………………………….……, having no
family, hereby nominate the person/persons mentioned below and confer on him/them
the right to receive, to the extent specified below, any gratuity the payment of which may
be authorised by the State Government in the event of my death while in service and the
right to receive on my death, to the extent specified below, any gratuity, which having
become admissible to me on retirement may remain unpaid on my death.
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
** The amount / share of the gratuity shown in this column should cover the whole
amount / share payable to the original nominee(s).
COMBINED APPLICATION FORM FOR GENERAL PROVIDENT
FUND
FINAL CLOSURE AND FAMILY PENSION
PART-I
FOR DEATH WHILE IN SERVICE / EXTENSION OF FAMILY PENSION CASES
(To be sent in Duplicate)
1. Name of the Government :

Employee (IN CAPITAL LETTERS).
Designation and Department. :
2. Date of Death. :
3. Date of Retirement in case of :

death after retirement.
4. Name of the Applicant / :

Guardian in case of minor.
5. Relationship of Applicant / :
Minor with Government
Employee.
6. Religion. :
7. Date of Birth in case of Minor :

with proof.
8. P.P.O. No. allotted by A.G’s. :

Office (applicable only for
revision cases)
9. G.P.F. No. with Departmental :

Suffix.
:
10. Residential Address with PIN :
Code.
MOBILE No. :
11. Place of Payment of Pension :

(a) Pension Pay Office.
(b) District Treasury.
(c) Sub-Treasury.
12. Are you in receipt of Family :

Pension from any other source? Yes No
2
13. If Yes, P.P.O. No. and Treasury :
from which it is drawn may be
furnished.
14. List of Family Members. :

Sl. Name Relationship Marital Date of Whether
No. Status Birth Handicapped/
Mentally
Retarded*
* Medical Certificate to be enclosed. :

15. Name of Guardian in case of
mentally retarded children.
16. Death Certificate / :

Legal Heir ship Certificate / :
Proof of Date of Birth in case of :
minor children. (Enclose separately.)
17. If the applicant is second wife, :

Date of Marriage with proof and
Details of first wife and children
born through both wives may be
furnished. [Copy of Death
Certificate / Court Orders for
divorcing the first wife, as the
case may be, to be furnished]
Place :
Date : Signature of the Applicant /
Guardian.
3
PART-II
TO BE FILLED IN BY THE DEPARTMENTAL OFFICER
1. A.G’s Office Reference No. in :

which the proposals were
returned with objections earlier.
2. Date of Beginning of Service. :
3. Date of Ending of Service. :
4. Gross Qualifying Service. :
5. Additional Qualifying Service :

due to Contingent Service.
6. Non-Qualifying Service. :
7. Net Qualifying Service. :
8. Scale of Pay :
9. Pay Last Drawn (Special Pay, :

Personal Pay drawn if any to be
shown separately).
10. Office served in the last three :

years.
11. Has the Subscriber filed any : Yes No

nomination for G.P.F.?
If YES, enclose the same in :

Original or Attested Copy.
12. a. Drawing Officer for G.P.F. :

PIN Code.

STD Code.
c. E_mail ID / FAX :
13. Treasury / PAO for G.P.F. :
14. a. Drawing Officer for D.C.R.G. :

PIN Code.
4

STD Code.
c. E_mail ID / FAX. :
15. Treasury / PAO for D.C.R.G. :
16. Details of Temporary Advance / :

Part Final Withdrawal
sanctioned in the last 12 months
(If no debit is drawn in last 12
months, the details of last debit
drawn should be specified.
CERTIFICATE
It is certified that:
1. All the particulars furnished above have been fully verified with
reference to office records and are found correct.
2. Advance / withdrawal from GPF was granted during the last 12

months as detailed in Column 16 above.
3. Provisional Pension has been / has not been paid (Details furnished
separately) @
4. Conditions laid down in Rule 11(2) and Rule 11(3) of the Tamil
Nadu Pension Rules, 1978 have been satisfied and the same has
been recorded in Service Book.
@ Strike out whichever is not applicable.

5
CHECK LIST / LIST OF ENCLOSURES
1. Service Book(s). [No. of Volumes] : [Enclosed / Not Enclosed]
2. Recent Passport size Photo, :

Specimen Signature / left hand
thumb impression (in the case of
illiterate) and Descriptive Roll of
the claimant, all in triplicate, duly
attested. (furnished in the
Annexure).
3. Attested copy of Legal Heir :

Certificate and Death Certificate.
4. Proof of Date of Birth in the case :

of children.
5. Dependency Certificate from the :

claimant in case of parent.
6. Income Certificate issued by :

Revenue Authorities.
7. Non-remarriage Certificate duly :

countersigned by any Gazetted
Officer.
8. Sanction order in respect of Non- :

Government Aided Educational
Institution cases and Missing
Employee / Pensioner cases..
9. Guardianship Certificate issued :

by Court of Law, if payments is to
be authorized through Guardian
on behalf of minor / mentally
retarded children.
10. Medical Certificate issued by :

Senior Civil Surgeon of the same
discipline where payment is to be
authorized to physically
handicapped children.
11. Copy of First Information Report :

in respect of missing employee /
pensioner cases.
12. Nomination for GPF /DCRG :
13. Death Certificate of first wife or

copy of Court Orders for divorce.
14. Copy of Adoption Deed in case of

adopted children.
15. Copy of Medical Certificate in the

case of Mentally Retarded
Children.
Place :
Date : Signature of the Head of Office
/ Department with Seal.
INSTRUCTIONS
1. Please send the application in DUPLICATE.
2. Please fill up all items in capital letters.
3. Incomplete application will not be processed.
4. Annual Account Statement of GPF need not be sent.
5. Last Fund deduction particulars mean deduction to GPF

before stopping recovery.
7
ANNEXURE
(To be sent in Triplicate)
1. Passport size Photo of the

Applicant / Guardian in case of
minor with Name.
Name of Applicant. :
Name of Guardian in case of
minor.
Counter Signature of the Head of

Office
with Seal.
2. Specimen Signature / Left hand

thumb impression of the
applicant / guardian.
3. Descriptive Roll of Applicant /

Guardian. [Personal Marks of
Identification].
8

[ FOR USE BY SUBSCRIBERS HAVING FAMILY ]
I, ……………………………………………………………………………….………… , hereby
nominate the person(s) mentioned below who is/are member(s) of my family as defined
in rule 2 of the General Provident Fund (Tamil Nadu) Rules, to receive the amount
that may stand to my credit in the fund as indicated below, in the event of my death
before that amount has become payable or having become payable has not been paid.
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
9

[ FOR USE BY SUBSCRIBERS HAVING NO FAMILY ]
I, ……………………………………………………………………………….………… , having
no family as defined in rule 2 of the General Provident Fund (Tamil Nadu) Rules hereby
nominate the person/persons mentioned below to receive the amount that may
stand to my credit in the fund as indicated below, in the event of my death before that
amount has become payable or having become
payable has not been paid.
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
10
NOMINATION FOR COMMUTATION OF PENSION

Nadu Civil Pensions (Commutation) Rules, 1944.
predeceases the
pensioner.
(1) (2) (3) (4) (5) (6)
receive the arrears of commutation of pension.
Place :
1.
2.
-/ Countersigned /-
Office Address:
11
NOMINATION FOR LIFE TIME ARREARS OF PENSION

Nadu Pension Rules, 1978.
predeceases the
pensioner.
(1) (2) (3) (4) (5) (6)
receive the arrears of pension.
Place :
1.
2.
-/ Countersigned /-
Office Address:
12
When the Government servant has a family and wishes to nominate one person or more
than one persons, thereof.
I, ……………………………………………………………………………….………… , hereby
nominate the person/persons mentioned below who is/are member(s) of my family, and
confer on him/them the right to receive, to the extent specified below, any gratuity, the
payment of which may be authorised by the Government of Tamil Nadu in the event of
my death while in service and the right to receive on my death, to the extent specified
below, any gratuity which having become admissible to me on retirement may remain
unpaid at my death.
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
** The amount / share of the gratuity shown in this column should cover the
whole amount / share payable to the original nominee(s).
13
When the Government servant has no family and wishes to nominate one person or
more than one persons, thereof.
I, ……………………………………………………………………………….……, having no
family, hereby nominate the person/persons mentioned below and confer on him/them
the right to receive, to the extent specified below, any gratuity the payment of which may
be authorised by the State Government in the event of my death while in service and the
right to receive on my death, to the extent specified below, any gratuity, which having
become admissible to me on retirement may remain unpaid on my death.
(1) (2) (3) (4) (5) (6)
Place :
1.
2.
-/ Countersigned /-
Office Address:
** The amount / share of the gratuity shown in this column should cover the whole
amount / share payable to the original nominee(s)

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COMBINED APPLICATION FORM FOR GENERAL

PROVIDENT FUND FINAL CLOSURE AND PENSION

1. Name of the Government

5. P.P.O. No. allotted by A.G’s.

6. G.P.F. No. with Departmental

10. Present Residential Address

11. Residential Address after

12. Place of Payment of Pension :

13. Whether the Pension is Yes No

If Yes, fraction proposed to be

15. If Yes, P.P.O.No. and Treasury P.P.O.No.

17. List of Family Members :

* Medical Certificate to be enclosed.

I do hereby declare to refund the pension or gratuity authorized by the

I hereby certify to make good any loss caused to the Government by

Employee with Date.

2. Date of Beginning of Service. :

3. Date of Ending of Service. :

4. Gross Qualifying Service. :

6. Additional Qualifying Service :

7. Net Qualifying Service. :

8. Total Period of Military Service :

10. Pay Last Drawn (Special Pay, :

11. Class of Pension applicable :

12. Whether any charges are

13. Office served in the last three :

14. a. Drawing Officer for G.P.F. :

16. a. Drawing Officer for D.C.R.G. :

b. Phone No. of the Office with :

18. Particulars of Last G.P.F. :

19. Details of Temporary Advance / :

@ Strike out whichever is not applicable.

1. Service Book(s). [No. of Volumes] : [Enclosed / Not Enclosed]

3. Sanction order in respect of :

5. Copy of First Information Report :

6. Nomination for General Provident :

7. Nomination for Death cum :

8. Nomination for Life Time Arrears :

9. Nomination for Commutation of :

10. Medical Certificate in original in :

11. Certificate of Medical Opinion of :

12. Ratification Order of Government :

15. Copy of Proceedings issued in the :

16. Copy of Government Order :

17. Copy of Adoption Deed, in case of :

18. Copy of Medical Certificate in the :

1. Please send the application in DUPLICATE.

2. Please fill up all columns in capital letters.

3. Incomplete application will not be processed.

4. Annual Account Statement of GPF need not be sent.

5. Last Fund deduction particulars mean deduction to GPF

6. For arriving at the Commuted value of Pension, dated

1. Joint Passport size Photo of the :

Name of Government Employee :

Name of the Spouse :

Counter Signature of the Head of

2. Specimen Signature / Left Hand : 1.

3. Descriptive Roll of Government : 1.

NOMINATION FOR GENERAL PROVIDENT FUND