New Pension Form
New Pension Form
New Pension Form
4. Religion :
7. Date of Birth
8. Date of Joining
9. Date of Retirement
MOBILE No. :
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.
Place :
Date :
Signature of
Government
5. Non-Qualifying Service. :
9. Scale of Pay :
c. e_mail ID / FAX
:
17. Treasury / PAO for D.C.R.G. :
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.
4. In case of Teachers, :
Non-Employment/Re-employment
Certificate.
6
14. Copy of the Chalan for refund of :
Gratuity received with Interest for
Military Service.
Place :
Date :
Signature of the Head of Office
/ Department with Seal.
INSTRUCTIONS
3.
3.
8
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.
1.
2.
-/ Countersigned /-
Office Address:
9
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.
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.
1.
2.
-/ Countersigned /-
Office Address:
10
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 :
Date : Signature of the Subscriber.
1.
2.
-/ Countersigned /-
Office Address:
11
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 pension.
Place :
Date : Signature of the Subscriber.
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.
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 :
Date : Signature of the Subscriber.
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.
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 :
Date : Signature of the Subscriber.
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).
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)
2. Date of Death. :
5. Relationship of Applicant / :
Minor with Government
Employee.
6. Religion. :
MOBILE No. :
Place :
Date : Signature of the Applicant /
Guardian.
3
PART-II
TO BE FILLED IN BY THE DEPARTMENTAL OFFICER
6. Non-Qualifying Service. :
8. Scale of Pay :
c. E_mail ID / FAX :
c. E_mail ID / FAX. :
CERTIFICATE
It is certified that:
1. All the particulars furnished above have been fully verified with
reference to office records and are found correct.
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.
Place :
Date : Signature of the Head of Office
/ Department with Seal.
INSTRUCTIONS
1. Please send the application in DUPLICATE.
ANNEXURE
Name of Applicant. :
Name of Guardian in case of
minor.
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.
1.
2.
-/ Countersigned /-
Office Address:
9
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.
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.
1.
2.
-/ Countersigned /-
Office Address:
10
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 :
Date : Signature of the Subscriber.
1.
2.
-/ Countersigned /-
Office Address:
11
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 pension.
Place :
Date : Signature of the Subscriber.
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.
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 :
Date : Signature of the Subscriber.
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.
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 :
Date : Signature of the Subscriber.
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)