पेंशन निराकरण के लिए 1 अक्टूबर 2002 के पूर्व प्रचलित फॉर्म
Updated: Mar, 12 2021
पेंशन निराकरण के लिए 1 अक्टूबर 2002 के पूर्व प्रचलित फॉर्म
FORM 5 (Omitted)
[Form 5 [............] omitted vide. Finance No. FB - 6/3/81/R-II/IV, dated 20-3-1981]
(Form for Sanctioning Pension) [...........]
पेंशन/मृत्यु-सह-सेवानिवृत्ति उपदान की स्वीकृति के लिये आवेदन का प्रारूप
प्ररूप 6-क
[म.प्र. शासन वि. वि. क्र. एफ. - 9-1-2002 नियम-चार दिनांक 2/8/03 द्वारा फार्म 6 के स्थान पर नवीन फार्म 6-क प्रतिस्थापित।]
[नियम 59 एवं 63 (7) देखिए]
(शासकीय सेवक द्वारा भरा जाए)
1. नाम .................................................................
2. पिता/पति का नाम...............................................
3. डाक का पता ......................................................
4. जन्म तारीख .....................................................
5. नियुक्ति की तारीख .............................................
6. सेवानिवृत्ति की तारीख .........................................
7. अंतिम/वर्तमान धारित पद ...................................
पदनाम/कार्यालय का नाम तथा पता...........................
8. सेवा कालावधि की मुख्य घटनाओं की विशिष्टियाँ –
(क) पदोन्नति/पदावनति –
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अनु.क्र.
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पदोन्नति/पदावनति की तारीख अथवा वर्ष
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पदोन्नति या पदावनति के पूर्व का वेतनमान
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पदोन्नति/पदावनति के पश्चात् का वेतनमान
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टिप्पणियाँ
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(1)
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(3)
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(5)
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(ख) शास्तियाँ
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अनु. क्र.
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तारीख/वर्ष
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शास्ति की प्रकृति/प्रकार
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(ग) अकार्य दिन कालावधि (ऐसी कालावधि, जिसको पेंशन की गणना के लिये विचार में नहीं लिया गया हो)
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अनु. क्र.
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कालावधि
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विशिष्टयाँ
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(1)
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(2)
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(3)
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9. सेवा के प्रारंभ में वेतन तथा वेतनमान
10. वर्तमान वेतन तथा वेतनमान
11. परिवार की विशिष्टियाँ –
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अनु. क्र.
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परिवार के सदस्यों का नाम
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जन्म तारीख
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शासकीय सेवक से संबंध
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विवाहित/अविवाहित
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यदि विकलांग हो तो उसका उल्लेख करें
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टिप्पणियाँ
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(1)
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(2)
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(3)
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(4)
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(5)
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(6)
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(7)
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12. जिला कोषालय का नाम, जहाँ से शासकीय
सेवक सेवानिवृत्ति लाभ लेना चाहता है।
13. विभिन्न सेवानिवृत्ति लाभों के लिये नामांकन
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अनु. क्र.
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मंजूर की गई राशि की विशिष्टियाँ पेंशन/उपदान आदि
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नामंकित व्यक्ति/व्यक्तियों का नाम
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संबंध
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जन्म तारीख
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(3)
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(5)
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मंजूरी की गई राशि की विशिष्टियाँ
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यदि कॉलम 3 में नामांकित व्यक्ति जीवित न हो तो अन्य नामांकित व्यक्ति की विशिष्टियाँ
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नाम
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संबंध
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जन्म तारीख
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मंजूर की गई राशि का अंश
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(7)
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(10)
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14. संयुक्त फोटोग्राफ/नमूना हस्ताक्षर/ऊँचाई एवं पहचान चिह्न के तीन सेट संलग्न हैं।
घोषणा - पत्र
मैं, एतद्वारा, घोषणा करता/करती हूँ कि ऊपर दी गई विशिष्टियाँ सत्य हैं। पेंशन या किन्हीं अन्य दावों के रूप में मुझे प्राप्त अधिक भुगतान की वसूली मेरे द्वारा प्राप्त की जाने वाली पेंशन या किसी अन्य राशि से की जा सकेगी। इस प्रयोजन के लिये क्षतिपूर्ति बंध-पत्र संलग्न है। उक्त जानकारी में किसी तथ्य को न छुपाया गया है और न ही गलत ढंग से प्रस्तुत किया गया है।
संलग्र - क्षतिपर्ति बंध - पत्र
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शासकीय सेवक के हस्ताक्षर
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FORM 7
[See Rule 59 (2)]
Form of Memo to the Audit Officer Forwarding the Pension Papers of a Government Servant.
No...............................................
Government of Madhya Pradesh
Department/Office..................
Dated the...............................
To,
The Accountant - General, M. P.
........................................
........................................
Subject - Pension papers of Shri/Shrimati/Kumari for authorisation of Pension.
1. The pension papers (as detailed in the list of enclosures) or Shri/Shrimati/ Kumari......................... of this Office/Department arc forwarded here with for further necessary action.
2. The receipt of the letter may be acknowledged
List of enclosures :-
Head of Office
(1)
(2)
1. Form 6 .................. ] containing the orders of the pension sanctioning authority, if necessary.
[Words omitted vide E. D. No. F. B. 1/3/86/R-IVIV, dated 20-3-1981.]
2. Medical certificate For invalidation (if the claim is for invalid pension).
3. Service Book.
4. Memorandum of average emoluments reckoning for pension.
5 (a) Two specimen signatures, duly attested by gazetted Government servant or in the case of pensioner not literate enough to sign his name/ two slips bearing the left hand thumb and finger inpressions, duly attested by gazetted Government officer and [Only two copies of passport size photograph of Government servant need be furnished.]
(b) Threecopies of pass port size joint photograph with wiseliusband duly attested by the Head of Office. [Only two copies of passport size photograph of Government servant need be furnished.]
(c) Two slips showing the particulars of height and identification marks, duly attested,
6. Explanation for delay, if any, beyond oneyear from the date of retirement of the (Government servant in forwarding Form 6 *[......] when necessary.
7. The fact of service in another office is not satisfactorily attested in the Service Book. Duly certified abstract from the Head of Office is attached.
8. (Written statement) if any of the Government servant as required by Rule 58 of the M. P. Services (Pension) Rules, 1976' duly admitted by them.
(i) If the Government servant is governed by Rule 47 of the M. P. Civil Services (Pension) Rules, 1976 and is ummarried or a widower or a widow:
(ii) If the (Government servant is governed by Rule 48 of the M. P. civil Service (Pension) Rules, 1976
If a Government servant is Compulsorily retired. Head of Office may forward the pension papers to the audit Officer even in the absence of papers of serial No. 5 [Words omitted vide E. D. No. F. B. 1/3/86/R-II/IV, dated 20-3-1981.]
Note - Pardanashin Ladies are exempted from joint photograph. In such a case declaration that applicant is pardanashin lady shall be enclosed.
FORM 8
[See Rule 66 (1)]
Form of Surety Bond
In consideration of the Governor of Madhya Pradesh (here after called the Government which expression shall include his successors and assigns) having agreed to settle the final accounts of Shri/Shrimati............... without production of "No Demand Certificate" from the PWD/PHED I hereby stand surety (which expression shall include my heirs, executors and administrators) for payment by OROM OT the said................. or rent and dues in respect of residence now allotted to him/her by the Government and also for any residence that may he allotted or that was allotted to the said........... from time to time by the Government, I, the surety, further agree and undertake to indemnify the Government against all loss and damage until delivery of vacant possession of the above said residence is made over to the Government.
I hereby also stand surety for any amounts that may be due by said................ to the Government by way of over payament of pay, allowances, leave salary, advances for conveyance, house building or other purposes, or any other dues.
The obligation undertaken by me shall not he discharged or in a way affected by an extension of time or any other indulgence granted by the Government to the said........
The guarantee shall remain in force till.
(i) The No demand Certificate "is issued by the PWD/PHED in favour (of the said..........
(ii) The head of office in which the said..................... was last employed, and in case he/she was drawing pay and allowances on gazetted/cited Government servants hill form, the concerned Audit Officer has certified that nothing is now due to the Government from the said............
The stamp duty on this instrument shall be bourn by the Government.
.....................................
Signature of the Surety
Signed and delivered by the said Surety at................ this ............ Day of............ in the presence of:
Signature............................
Address and occupation of witness...................
2. Signature........................
Address and occupalion of witness...................
Certified that Shri/Shrimati......................is a permanent Goverment servant. He/She shall not attain the age of superannuation within 2 year from the dale he/she stands surety.
Signature of the Head of the Department or Head
[word 'Head of office' in serted vide Not. No. F. D. 6-1-77/R :- II/IV/dated 1.5.77. Published in M. P. Rajpatra – Part IV (go) dt 29.7.77]
of Office in which the surely is employed
The bond is hereby accepted............
Signature and designation [of the head of office]
[word 'Head of office' in serted vide Not. No. F. D. 6-1-77/R :- II/IV/dated 1.5.77. Published in M. P. Rajpatra – Part IV (go) dt 29.7.77]
for and on behalf of the Governor of
Madhya Pradesh
FORM 9
[Form No 9 Amended vide F. D. No. B-6/1/77/R-11/IV/dated 1.2.77.]
[See Rule 69 (2) (b)]
Form of Memo to the member or members of family of a deceased Government servant where valid nomination for the grant of the Death-Cum-retirement grattity exists
No...............................................
Government of Madhya Pradesh
Department/Office.......................
Dated the...................................
To,
..................................
Subject – Payment of death-cum-retirement gratuity In respect of the late Shri/ Shrimati...................
In terms of the nomination made by the late Shri/Shrimati.............(Designation)............. in the Office/Department of................... Death cum retirement gratuity is payable to his/her nominee (s). A copy of the said nomination is the enclosed herewith.
2. It is requested that a claim for the grant of the gratuity may be submitted by you in the enclosed form II
3. Should any contingency have happended since the date of making the nomination, so as to render the nomination invalid, in whole or in part, precise datails of the contingency may kindly be stated.
.......................
Head of Office
FORM 10
[See Rule 69 (2) (b)]
Form of memo to the members of the family of a deceased Government servant where valid nomination for the grant of the death-cum-retirement gratuity does not exist
No...............................................
Government of Madhya Pradesh
Department/Office.......................
Dated the............... 20................
To,
...........................
Subject - Payment of death-cum retirement gratuity In respect of the late Shri/ Shrimati......
In terms of Rule 5 of the M. P. Civil Services (Pension) Rules, 1976, a death-cumretirement gratuity is payable to the legal heirs of the Shri/Shrimati............. (Designation)................... in the Office/Department of................
2. It is requested that a claim for the payament of grautity may be submitted by legal heirs in the enclosed form II, as soon as possible with the proof of legal heir-ship/ sureties in the Form 24.
(may file on affidavit giving full delails of family writh age and relation ship, along with Form 24, where payment are requerted writhout succession certificate and the amt in below Rs. 10,000/-
पेंशन/मृत्यु-सह-सेवानिवृत्ति उपदान मंजूर करने के लिये प्ररूप
प्ररूप 6-ख
[म.प्र. शासन वित्त विभाग क्र. एफ. -9-1-2002/नियम/चार/दिनांक 2.8.03 से फार्म 11 के स्थान पर प्रतिस्थापित।]
[पेंशन नियम 57 (1), 59, 61 (1), एवं (7)]
(कार्यालय प्रमुख द्वारा भरा जाए)
1. शासकीय सेवक का नाम एवं पदनाम.....................................
2. जन्म तिथि ......................................................................
3. प्रथम नियुक्ति की तारीख ...................................................
4. सेवा-निवृत्ति की तारीख .....................................................
5. कुल सेवा कालावधि (4-3) ...................................................
6. कालावधि, जिसकी गणना पेंशन की गंणना ............................
के लिये नहीं की जानी है।
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अनु.क्र.
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कालावधि
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पेंशन के लिये हिसाब में नहीं लेने का कारण
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टिप्पणियाँ
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कब से
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कब तक
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(3)
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(4)
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7. पेंशन हेतु शुद्ध अर्हकारी सेवा (5-6) वर्ष.............. माह........... दिन...............
8. वर्तमान वेतनमान
9. संपूर्ण सेवा की कालावधि के दौरान समय-समय पर प्राप्त वेतन की विशिष्टियाँ :-
(1) नियुक्ति की तारीख को वेतन..................तथा वेतनमान...............
(2) सेवा की कालावधि के दौरान समय मान में वेतन निर्धारण :-
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अनु.क्र.
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वर्ष
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धारित पद का नाम
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वेतनमान
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प्रारंभिक वेतन
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वेतनवृद्धि की राशि
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वेतनवृद्धि के पश्चात् वेतन
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टिप्पणियाँ
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(1)
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(2)
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(3)
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(4)
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(5)
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(6)
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(7)
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(8)
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(3) अंतिम उपलब्धि - 1. मूल वेतन................... 2. मंहगाई भत्ता..................
10. औसत उपलब्धियां की गणना -
(अंतिम 10 माह मेंप्राप्त कुल उपलब्धियों के आधार पर)
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अनु.क्र.
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धारित पद का नाम
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माह एवं वर्ष
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मासिक उपलब्धियाँ
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(1)
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(2)
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(3)
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(4)
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योग :...................
11. पेंशन की प्रस्तावित राशि
12. लंबित विभागीय जाँच की विशिष्टियाँ
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अनु.क्र.
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आरोप पत्र प्रस्तुत करने की तारीख
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विशिष्टियाँ
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ऐसी वित्तीय हानियाँ, जिन्हेंजाँच के आरोपों का कारण सरकार को वहन करना होगा
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विभागीय जाँच पर विभागीय अंतिम निर्णय की संभावित तारीख
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(1)
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(2)
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(3)
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(4)
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(5)
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12-क. लंबित न्यायालयीन मामलों की विशिष्टियाँ.
13. उपदान राशि की गणना अंतिम:-
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अनु.क्र.
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अंतिम उपलब्धियाँ
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अर्हकारी सेवा (अर्धवार्षिकी में)
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उपदान राशि की गणना, अर्हकारी सेवा X अंतिम उपलब्धियाँ x 1/4
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मंजूर किया जाने वाला उपदान
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(1)
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(2)
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(3)
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(4)
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(5)
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14. परिवार पेंशनभोगी का नाम :- (पेंशन नियम 46 के अनुसार क्रम से लिखें)
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अनु.क्र.
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परिवार पेंशन-भोगी का नाम
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जन्म तिथि
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शासकीय सेवक संबंध
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टिप्पणियाँ
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(1)
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(2)
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(3)
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(4)
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(5)
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15. परिवार पेंशन के लिये गणना :- राशि - कालावधि - कब से कब तक
(क) बढ़ी दर से.............................
(ख) सामान्य दर से............................
16. तारीख, जिसको पेंशन प्रारंभ होनी हो...........................
17. कोषालय का नाम, जहाँ से पेंशन/उपदान...........................
की राशि प्राप्त की जानी है।
18. शासकीय सेवक के विरुद्ध अतिशेष धनराशि की
विशिष्टियाँ (आवास किराया एवं अल प्रभार सहित)
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अनु.क्र.
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विशिष्टियाँ
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अतिशेष धनराशि
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वसूली हेतु सक्षम प्राधिकारी के आदेश क्र. एवं तारीख
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टिप्पणी
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(2)
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(3)
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(5)
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19. शासकीय आवासगृह का पता, यदि आवंटित हो :-...........................................
कार्यालय प्रमुख का घोषणा -पक्ष
प्रमाणित किया जाता है कि श्री/श्रीमती...................... के संबंध में दी गई उपरोक्त विशिष्टियाँ सत्य तथा सही हैं तथा इनका सत्यापन संबंधित शासकीय सेवक के कार्यालय अभिलेख तथा सेवापुस्तिका से कर लिया गया है।
संलग्न :- क्षतिपूर्ति बंधपत्र
कार्यालय प्रमुख के हस्ताक्षर
तारीख :-.........................
पदनाम (मुद्रा सहित)
क्षति पूर्ति बन्ध पत्र
यतः, मैं (नाम)................ मध्यप्रदेश शासन के अधीन.......... पद धारण कर रहा हूँ।
और, यतः, मैं............................ में अंतर्विष्ट शासकीय आदेशों के अनुसरण में, शासकीय सेवा से सेवानिवृत्ति हो रहा हूँ/निवृत्ति पूर्व छुट्टी पर जा रहा हूँ और तद्नुसार मेरे उक्त पद का कार्यभार श्री.................................. को सौंप रहा हूं। और यतः, शासन या मेरे उत्तराधिकारी के लिये यह संभव नहीं है कि शासन के अथवा शासन को देय उस समस्त धन के लेखाओं की संपूर्ण रूप से या पर्याप्त रूप से परीक्षा, जिसकी अभिरक्षा या वसूली के लिये मैं उत्तरदायी हूँ या मेरे प्रभार में की शासकीय संपत्ति के स्टॉक की जाँच पड़ताल उस तारीख से पूर्व, जिसको मेरे उक्त पद से मुझे कार्यमुक्त होना है, उपलब्ध समय के भीतर की जासके।
और, यतः मेरे लिये यह बाध्यकर है कि मैं पूर्वोक्त समस्त धन और सम्पत्ति का सही तौर पर तथा निष्ठापूवर्क लेखा जोखा दूँ, तथा किसी ऐसी हानि या क्षति के लिये सरकार की क्षतिपूर्ति करूँ, जो कि उक्त पद के मेरे कार्यकाल के दौरान हुई हो अथवा उठाई गई हो और जिसका मेरे कार्यमुक्त होने के पश्चात् पता चले।
अतएव, एतद्द्वारा मैं, सहमत हूँ और घोषित करता हूँ कि उस दशा में, जब किसी ऐसी हानि या नुकसान का अथवा पेन्शन संबंधी लाभ अथवा वेतन निर्धारण आदि में अधिक भुगतान का या किसी अन्य मामले का पता चलता है और उसे स्पष्ट करने का मुझे अवसर देने के पश्चात् एवं उसके संबंध में मेरे स्पष्टीकरण पर, बशर्ते वह विहित समय के भीतर प्रस्तुत किया गया हो, विचार करने के पश्चात् राज्य सरकार का यह समाधान हो जाए कि ऐसी हानि या नुकसान मेरी ओर से उपेक्षा, चूक, अवचार, अथवा अवज्ञा के कारण हुई और लिखित सूचना द्वारा मुझसे अपेक्षा की जाए मैं उस हानि नुकसान की अथवा पेंशन, पेंशन संबंधी लाभ, वेतन निर्धारण आदि में अधिक भुगतान की अथवा किसी अन्य मामले में प्रतिपूर्ति करूँ तो मैं तुरन्त ऐसा करने का या ऐसी रकम का भुगतान करने का वचन देता हूं।
मैं इस बात के लिए सहमत हूँ तथा घोषित करता हूँ कि यदि मैं, मुझसे माँगी गई राशि का युक्तियुक्त समय के भीतर भुगतान करने में असफल रहता हूँ तो उस राशि की वसूली, सिविल वाद द्वारा या भू-राजस्व की बकाया तौर पर मुझसे की जा सकेगी।
सरकार, किसी स्टाम्प शुल्क को, जो इस बंध-पत्र पर प्रभार्य हो, वहन करने हेतु सहमत है। मेरे द्वारा तारीख............... को हस्ताक्षरित किया गया।
(हस्ताक्षर)..........................
(कार्यालय)..........................
टिप्पण - कोई भी पेंशन मामला, इस आशय का प्रमाण-पत्र संलग्न किये बिना कि संबंधित अधिकारी के विरुद्ध कोई जाँच लंबित नहीं है, जिसके परिणामस्वरूप उस संपत्ति की, जिसकी हानि हुई है, राशिया मूल्य की वसूली हो सकती है, अग्रेषित नहीं किया जाना चाहिये।
शासकीय सेवक के संयुक्त फोटोग्राफ/नमूना हस्ताक्षर/ऊँचाई तथा पहचान चिह्न
संयुक्त संचालक, कोष लेखा एवं पेन्शन/कोषालय अधिकारी को दो प्रतियों में भेजा जाए । कार्यालय प्रमुख, कार्यालयीन अभिलेख हेतु एक प्रति रखे। शासकीय सेवक द्वारा तीन प्रतियों में कार्यालय प्रमुख को दिया जाए।
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प्रमाणित फोटोग्राफ
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1. शासकीय सेवक की पत्नी/पति के साथ पासपोर्ट आकार का अनुप्रमाणित संयुक्त फोटोग्राफ
शासकीय सेवक का नाम/पदनाम नमूना हस्ताक्षर 1........................
2........................
अंगूठे का निशान (हस्ताक्षर न करने की दशा में)1........................
2........................
3........................
(क) ऊँचाई ..........................
(ख) पहचान चिह्न..........................
शासकीय सेवक का वर्तमान तथा स्थायी पता
स्थान :कार्यालय प्रमुख के हस्ताक्षर
तारीखः पदनाम (मुद्रा सहित)
FORM 12
[See Rule 69 (3)]
Form of memo to the widow/widower of a deceased Government servant for grant of contributory family pension
No................................................
Government of Madhya Pradesh
Department Office........................
Dated the.....................................
To,
Shrimati/Shri.....................
..........................................
..........................................
Subject. – Payment of contributory family pension in respect of late Shri/Shrimati................................
In terms of Rule 47 of the M. P. civil Service (Pension) Rules, 1976, a contributory family pension is payable to you as widow/widower of Late Shri/Shrimati........................
(Designation), in the Office/Department.........................
2. You are advised that a claim for the grant of contributory family Pension may be submitted in the enclosed Form 13.
3. The contributory family pension will he payable till your death or remarriage whichever event occurs earlier. In the event of your death or re-marriage the contributory family pension shall granted to "the child or children, if any, through the guardian.
.........................
Head of Office
Note- Where there are more widows than one, family pension is payable to all widows in equal shares and all of them should be asked separately to application.
परिवार पेंशन/मृत्यु-सह-सेवा निवृत्ति उपदान के लिये आवेदन-पत्र
प्ररूप 6- ग
[नियम 69 (2), 69 (3) तथा 71 (2) देखिए]
[वि. वि. क्र. एफ - 9-1-2002/नियम/चार/दि. 2-8-03 से फार्म 13 के स्थान पर प्रतिस्थापित ।]
(आवेदक द्वारा भरा जाए)
1. मृत शासकीय सेवक का नाम.................................................
2. मृत शासकीय सेवक के पिता/पति का नाम .......................................
3. मृत शासकीय सेवक के कार्यालय का नाम....................................
तथा पता और धारित अंतिम पद का नाम
4. मृत शासकीय सेवक की मृत्यु की तारीख....................................
(मृत्यु प्रमाण-पत्र संलग्न करें)
5. मृत शासकीय सेवक के परिवार की विशिष्टियाँ ...................................
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अनु.क्र.
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परिवार के सदस्यों
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जन्म तारीख
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मृत शासकीय सेवक के संबंध
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टिप्पणी
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(1)
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(2)
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(3)
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(4)
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6. यदि मृत व्यक्ति पेंशन भोगी था तो -
(क) सेवा-निवृत्ति की तारीख............................................
(ख) पेंशन भुगतान आदेश क्र. (यदि कोई हो) ........................
(ग) पेंशन मंजूर करने वाले अधिकारी का नाम, ..........................
पता तथा पदनाम
7. आवेदक की विशिष्टियाँ -
(क) नाम..........................................
(ख) पिता/पति का नाम.........................................
(ग) जन्म तारीख (पुत्र/पुत्री) के मामले में...........................
जन्म प्रमाण-पत्र संलग्न करें)
8. आवेदक का डाक का पता.........................................
9. जहाँ परिवार पेंशन सरंक्षक के माध्यम से.......................
भुगतान की जानी हो, वहाँ संरक्षक का नाम/.......................
पता एवं पुत्र/पुत्री से संबंध में –
10. कोषालय का नाम, जहाँ से भुगतान.........................
लेना चाहता है—
11. अनुप्रमाणित फोटोग्राफ, नमूना हस्ताक्षर ऊँचाई..........
तथा पहचान चिह्न संलग्न हैं
मैं, एतद्द्वारा घोषणा करता हूँ कि ऊपर दी गई विशिष्टियाँ सत्य तथा सही हैं। उपरोक्त जानकारी में कोई तथ्य छिपाया नहीं गया है या गलत ढंग से प्रस्तुत नहीं किया गया है। पेंशन या किन्हीं अन्य दावों के रूप में मेरे द्वारा प्राप्त अधिक भुगतान की वसूली, मेरे द्वारा प्राप्त की जाने वाली पेंशन या अन्य राशि से की जा सकेगी। इस प्रयोजन के लिये क्षतिपूर्ति बंधपत्र संलग्न हैं।
संलग्न :- क्षतिपूर्ति बंधपत्र
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| तारीख :- | आवेदक के हस्ताक्षर |
FORM 14
[See Rule 69 (4)]
No...............................
Form of Memo to the Member of the Family of a Deceased Government servant where valid Nominations for the Grant of Non-Contributory Family Pension Exists.
No...............................................
Government of Madhya Pradesh
Department Office......................
Dated the...................................
To,
............................
............................
Subject. - Payment of contributory family pension in respect of late Shri/Shrimati................
In terms of the nomination made by the late Shri/Shrimati................... (Designation), in the Office/Department of................... a non-contributory family pension is payable to you and claim, may be submitted by you in the enclosed Form 16.
3. Should any contingency have happened since the date of making the nomination so as to render the nomination invalid, details of the contingency may kindly be stated
Head of Office
FORM 15
[Rule 69 (4)]
Form of Memo to the Member of the Family of a Deceased Government servant where valid nominations for the grant of non-contributory Family Pension does not exists.
No..............................................
Government of Madhya Pradesh
Department/Office.....................
Dated the..................................
To,
............................
............................
Subject. – Payment of non-contributory family pension in respect of the late Shri/Shrimati..............
In terms of Rule 48 M. P. Civil Services (Pension) Rules, 1976, a non-contributory family pension is payable to the family of thelate Shri/Shrimati................. (Designation), in the Office/Department of ............... as follows:
(a) (i) to the eldest surviving widow or the husband;
(ii) failing a widow/husband, to the eldest surviving son;
(ii) failing (i) and (ii) above, to the eldest surviving unmarried daughter, and
(iv) failing, these to the eldest surviving widowed daughter, and
(b) If there are no surviving member of the family as at clause (a) above -
(i) to the father,
(ii) failing the father, to the mother.
(iii) failing the father and mother, to the eldest surviving brother below eighteen years of age,
(iv) failing (i), (ii) and (iii) above, to the eldest surviving unmarried sister,
(v) failing the above, to the eldest surviving widowed sister
(c) No non-contributory family pension is payable to a person mentioned in clause (b) above without production of reasonable proof that such person was dependant on the deceased for support.
2. I am to suggest that a claim for the non-contributory family Pension may be submitted in the enclosed Form 16 as soon as possible. If you have a prior claim to it in accordance with gradation given above, you are requested to furnish an affidavit to the effect that there is other surviving member of the family of Shri/ Shrimati................................ ranking above you in the order given in the first paragraph. If in the light of the above gradation, you have no prior claim to the noncontributory family pension, you are requested to intimate this Office/Department the name, address and relationship with the deceased, of the person who according to your knowledge has a prior claim to the non-contributory family pension. Any false information given or declaration made by you in this connection will render you liable to legal action.
Head Office
FORM 16
[See Rule 69 (4) and 71 (3)]
[Amended vide F. D. No. B-6. B- 6 No. B/6/1/77/R-II/IV, dt. 1-2-1977.]
Form of Application for the grant of non-contributory Family Pension on the death of a Government servant/Pensioner
1. Name of the applicant.................................
2. (i) Name of the guardian in case.................
(ii) The applicant is, minor...............................
Relationship or the guardian...........................
3. Name of the deceased Government Servant
Pensioner.
4. Relationship of the applicant with the
deceased Government servant/Pensioner.
5. Date of death of the Government servant/
Pensioner.
6. Office Department in which the deceased
Served last.
7. (i) Date of birth of applicant.
(ii) Date of birth of the guardian in case
the applicant is a minor.
8. Full address of the applicant/guardian.
9. Name of the Treasury or sub-Treasury at
which payment is desired.
10. Enclosure:
(i) Two specimen signature of the applicant.
duly attested (to be furnished
on two separate sheets).
(ii) Two copies of a passport size photograph
of the application duly attested. [Pardanashin ladies are exempted from joint photograph. If photograph is not enclosed declaration that beneficiary is Pardnashin lady shall enelosed.]
(iii) Two slips each bearing left hands
thumb and Finger impression of the
applicant duly attested. [To be furnished in case the applicant is not literate enough to sign his name.]
(iv) Descriptive roll of the applicant, duly
attested, including (a) height and (b)
personal marks, if any. on hand, face
etc. (To be furnished in duplicate).
(v) If the applicant belongs to a category
mentioned at (b) of item 11 he/she
should produce reasonable proof of
his/her dependence on the deceased
Government Servant/Pensioner for
support.
(vi) If the applicant is minor brother of
the deceased Government Servant/
Pensioners certificate of age (in original
with two attested copies showing the
date of birth), (Should be furnished)
(The original will be returned to the
applicant after necessary verification).
(vii) Affidavit (please see paragraph 2 of
Form 15).
11. Name of ages of surviving relatives of the deceased Government servant/pensioner'
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Name
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Date of birth by Chrestian Era
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(1)
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(2)
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(a) Widow/husband/sons
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Unmarried daughters
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Widowed daughter
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(b) Father
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Mother
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Brothers below the age of 18 years
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Unmarried sister
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Widowed sister
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12. Signature of thumb impression of the applicant.
13. Attested by :-
Name Full address - Signature
(i)
(ii)
14. Witness :
(i)
(ii)
Note :- (1) Attestation should be done by two gazetted Government servants or by two or more persons of respectability in the twon, village or Pargana in which the applicant resides.
(2). If the applicant is a minor, the enclosure against item 10 (i) to (iv) are to be furnished by the guardian.
In the case of more than one widows, name of eldest surviving widow to be mentioned which should be with reference to seniority according to date of marriage and not with reference of age.
परिवार पेंशन/मृत्यु-सह-सेवानिवृत्ति उपदान मंजूर करने के लिये प्ररूप
प्ररूप 6 – घ
[नियम 69 (7) एवं 70 (6) देखिए]
[वि. वि. क्र. एफ - 9-1-2002/नियम/चार/दि. 2-8-03 से फार्म 17 के स्थान पर प्रतिस्थापित।]
(कार्यालय प्रमुख द्वारा भरा जाए)
1. मृत शासकीय सेवक का नाम ........................................
2. पिता/पति का नाम.......................................................
3. अंतिम धारित पद .......................................................
4. कार्यालय का नाम (जहाँ वह नियोजित था/थी) .................
5. जन्म तारीख..............................................................
6. नियुक्ति की तारीख ....................................................
7. मृत्यु की तारीख .........................................................
8. सेवा कालावधि.......... वर्ष ............माह.............दिन...............
9. वेतनमान ..................................................................
10. अंतिम उपलब्धियाँ (1) मूल वेतन ...........(2) मंहगाई भत्ता ..................
11. परिवार पेंशन भोगी का नाम तथा मृत .......................................
शासकीय सेवक से संबंध
12. मंजूर की गई परिवार पेंशन –
(क) बढ़ी दर से.............. तारीख..............से रुपये..................
(ख) सामान्य दर से .............. तारीख.................से रुपये..................
13. परिवार पेंशन प्रारंभ होने की तारीख .............................
14. उपदान राशि की गणना :-
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अ.क्र.
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अंतिम उपलब्धियाँ
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अर्हकारी सेवा (अर्धवार्षिकी में)
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उपदान राशि की गणना, अर्हकारी सेवा X अंतिम उपलब्धियाँ x 1/4
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मंजूर किये जाने वाला उपदान
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(1)
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(2)
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(3)
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(4)
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(5)
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15. पेंशन उपलबिधयों को प्राप्त करने वाले व्यक्तियों की विशिष्टियाँ :-
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अ.क्र.
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नाम
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मृत व्यक्ति के संबंध
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देय राशि
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देय राशि का आधार
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(1)
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(2)
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(3)
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(4)
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(5)
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16. अवयस्कों के मामलों में संरक्षक का नाम, जो .......................................
मृत्यु-सह-सेवानिवृत्ति उपदान एवं परिवार पेंशन ........................................
प्राप्त करेगा
17. संरक्षक का डाक का पता ..................................................................
18. जिला कोषालय का नाम, जहाँ से वह भुगतान प्राप्त करना .....................
चाहता है/चाहती है।
19. मृत शासकीय सेवक के विरुद्ध अतिशेष भुगतानों की विशिष्टियाँ
(आवास किराया/जल प्रभारों को सम्मिलित करते हुए) :-
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अनु.क्र.
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विशिष्टियाँ
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अतिशेष धनराशि
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वसूली हेतु सक्षम प्राधिकारी के आदेश क्र. एवं तारीख
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टिप्पणी
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(1)
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(2)
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(3)
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(4)
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(5)
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1.
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2.
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3.
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(कार्यालय प्रमुख का घोषणा-पत्र)
प्रमाणित किया जाता है कि स्वर्गीय श्री/श्रीमती.................. के संबंध में दी गई उपरोक्त विशिष्टियाँ सत्य तथा सही हैं तथा इसका सत्यापन संबंधित शासकीय सेवक के कार्यालय अभिलेख तथा सेवापुस्तिका से कर लिया गया है।
| स्थान : | कार्यालय प्रमुख के हस्ताक्षर |
| तारीख : | पदनाम (मुद्रा सहित) |
फोटोग्राफ/नमूना हस्ताक्षर/ऊँचाई एवं पहचान चिह्न
संयुक्त संचालक, कोषलेखा एवं पेंशन/कोषालय अधिकारी को दो प्रतियों में भेजा जाए । कार्यलय प्रमुख कार्यालय के अभिलेख हेतु एक प्रति रखेगा। आवेदक को तीन प्रतियों के प्रकरण को कार्यालय प्रमुख को प्रस्तुत करना होगा।
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फोटोग्राफ
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आवेदक का पासपोर्ट आकार का अनुप्रमाणित फोटोग्राफ
आवेदक का नाम तथा मृत शासकीय सेवक से उसकासंबंध
| नमूना हस्ताक्षर | 1. | 2. | 3. |
| अंगूठे का निशान (यदि हस्ताक्षरित नहीं है) | 1. | 2. | 3. |
| स्थान : | कार्यालय प्रमख के हस्ताक्षर | ||
| ताराख : | पदनाम (मुद्रा सहित) | ||
2. ये संशोधन 2 अक्टूबर, 2002 से प्रवृत्त हुए समझे जाएंगे।
मध्यप्रदेश के राज्यपाल के नाम से तथा आदेशानुसार
हस्ता/- (पी. सी. वर्मा)
उपसचिव,
FORM 18
[See Rule 69 (6)]
Form of letter to the Audit Officer forwarding Papers for Grant of Family Pension and Death-cum-retirement Gratuity to the Family of a Government servant who dies while in service
No................................................
Government of Madhya Pradesh
Department/Office........................
Dated the.....................................
Dated the.....................................
Το,
The Accountant General,
Madhya Pradesh,
Subject - Grant of family pension and death-cum-retirement gratuity.
I am to inform you that Shri....................... (designation) died on................ His family, has become eligible for the grant of family Pension and death-cum-retirement gratuity. Form 17 duly completed, [..........] is forwarded herewith for further necessary action. [[.............] Omitted vide F. D. No. 1-B 6/1/77/R-II/IV, dated 10-5-1077, M. P. Rajpatra 4 (Ga) dated 29-7-1977.]
2. Your attention is invited to the list of enclosures which is forwarded herewith.
3. The receipt of this letter may be acknowledged and this Department Office informed that necessary, instructions for the disbursement of family pension and deathcum-retirement gratuity have been issued to the Treasury officer concerned.
Head of Office
List of Enclosures
*1. Specimen signature or left hand thumb and Finger impression of the beneficary, duly attested.
**2 Two attested copies of passport size photograhp of the beneficiary.
3. Descriptive Roll of the beneficiary, duly attested.
*Delate whenever not required.
**Pardanashin ladies are exemplied from submission of photograph. In such cases declaration that beneficiary is pardanshin lady shall be enclosed.
FORM 19
[See Rule 71 (2)]
Form of Letter Sanctioning Contributory Family Pension to the Child or Children of a Retired Government Servant who dies after Retirement but does not Leave Behind a Widow/Widower
No................................................
Government of Madhya Pradesh
Departiment/Office........................
Dated the.....................................
To,
The Accountant General
Madhya Pradesh,
Subject - Grant of family pension to the child/children.
I am to inform you that Shri/Shrimati.............................. formerly ................... (Designation).............in this Department/Office was sanctioned pension of Rs...............with effect from............... of his/her retirement from service.
2. Intimation has been received in this Department/Office that a Shri/Shrimati............... died on..................... and that at the time of death left no widow/widower but was survived by the following children-[The names of children should be mentioned in the order of eligibility mentioned in Rule 47 of the M.P. Civil Services (Pension) Rules, 1976. Children born, as a result of marriage took place before the retirement of the Government servant or children accepted legally before retirement should only be included.]
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S.No.
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Name
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Son/Daughter
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Date of Birth in Christian Era
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Date from which family pension ceases to be payable
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(1)
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(2)
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(3)
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(4)
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(5)
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In terms of Rule 47 of the M.P. Civil Service (Pension) Rules, 1976, amount of contributory family pension has become payable to the children in the order mentioned above. The contributory family pension will be payable to Shri/Shrimati.. who is the guardian on behalf of the minor children.
4. Sanction for grant of contributory family pension is accorded as under :
(a) At enhanced rate of Rs. ............... P.m. from................ to...........;
(b) At normal rate of Rs............. P. m. from.......... to. This sanction is subject to the provision of sub-rule (b) of Rule 47 of the M.P. civil Services (Pension)
Rules, 1976.
5. The contributory family pension is debitable to the Head...............
6. Attention is invited to the information furnished in the endorsed List.
7. The receipt of this letter may kindly be acknowledged and this Department/Office informed that necessary instructions for the payment of contributory family pension to the guardian have been issued to the Treasury Officer concerned.
(Head of Office)
List of Enclosures
1. Permanent address of the guardian.
2. Place of payment (Government Treasury or Sub-treasury).
3. Specimen signature of 'left hand finger impressions of the guardian, July attested. [To be furnished in the case of the guardian who is not literate enough to sign his/her name.]
4 Two attested copies of a passport size photograph of the guardian. [If lady guardian is pardanashin lady and does not wish to furnish photograph, a declaration of being a pardanashin lady shall be endorsed.]
5. Descriptive Roll of the Guardian, duly attested.
FORM 20
[See Rule 71 (C) (iv)]
Form of Letter Sanctioning Family Pension to the Child or Children on the Death or Re-marriage of Widow/Widower in respect of Contributory Family Pension.
No...............................................
Government of Madhya Pradesh
Department Office.......................
Dated the....................................
To,
The Accountant General,
Madhya Pradesh,
Subject - Grant of family pension to the child/Children.
Shri/Shrimati.............................widow/widower of late Shri/ Shrimati................... formerly................ (Designation) in this Department/Office, was sanctioned contributory family pension of Rs................. with effect from the............... This contributory family pension was sanctioned till the death or remarriage of the widow/widower.
2. Intimation has been received in this Department/Office that a Shri/Shrimati.................... died/re-married on....................
3. At the time of death/re-marriage, Shri/Shrimati.............................following children:
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S.No.
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Name
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Son/Daughter
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Date of Birth in Christian Era
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Date from which family pension ceases to be payable
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(1)
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(2)
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(3)
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(4)
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(5)
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1.
2.
3.
4.
5.
6.
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|
4. In terms of Rule 47 of the M.P. Civil Service (Pension) Rules, 1976, amount of contributory family pension has become payable to the children in the order mentioned above. The contributory family pension will be payable on behalf of the minors to Shri/ Shrimati...................... who is the guardian.
5. Sanction for grant of contributory family pension to the children mentioned above is accorded as under.
(a) At enhanced rate of Rs. ............... P.m. from................. to........,
(b) At normal rate of Rs............ P. m. from.......... to. This sanction is subject to the provision of sub-rule (6) of Rule 47 of the M. P. civil Services (Pension) Rules, 1976.
6. The contributory family pension is debitable to the Head........
7. Attention is invited to the information furnished in the endorsed List.
8. The receipt of this letter may kindly be acknowledged and this Department/Office informed that necessary instructions for the payment of contributory family pension to the guardian have been issued to the Treasury Officer concerned.
.........................
(Head of Office)
List of Enclosures
1. Permanent Address of the Guardian;
2. Place of payment (Government Treasury or Sub-Treasury).
3. Specir en Signature or left hand thumb and Finger impression of the Guardian, duly attested. [The names of children should be mentioned in the order of eligibility mentioned in Rule - 47 of the M. P. Civil Services (Pension) Rules, 1976. Children born as a result of marriage which took place before the retirercent of the Government servant or children adopted legally before retirement should only be included.]
4 Two attested copies of a Passport size photograph of the Guardian. [If a Retired Governenment Servant is in receipt of the Service-Gratuity or pensiondies with in 5 years of retirement from service including Compulsory Retirement as a penalty and the sun received at the time of death of, such Gratuity or Pension including adhoc increase, together with death-cum-Retirement Gratuity and the Commuted value of any portion of Pension are less than the amount equal to 12 times of his emoluments A Residuary-Gratuity equal to deficiency in payable to family.]
5. Descriptive Roll of the Guardian, duly attested.
FORM 21
Form of Application for the grant of Residuary Gratuity on the Death of the Pensioner
(To be filled in separately by each Applicant)
1. Name of Applicant.
2. (i) Name of the guardian in case the
(ii) Date of Birth of Guardian.
3. Name of the Deceased Pensioner.
4. Office/Department in which the deceased
Pensioner servant last.
5. Date of Death of the Pensioner.
6. Date of Retirement of the Deceased
Pensioner.
7 Amount of monthly Pension (including ad
hoc increase, if any) sanction to Deceased
Pensioner.
8. Amount of Death-cum-Retirement Gratuity
received by the Deceased Pensioner. [If a Retired Governenment Servant is in receipt of the Service-Gratuity or pensiondies within Five years from the date of his retirement from service including Compulsory Retirement as a penalty and the sums actually received by him at the time of his death on account of such Gratuity or Pension including ad hoc increase, if any together with the death-cumRetirement Gratuity and the Commuted value of any portion of Pension commuted by him are less than the amount equal to 12 times of his Emoluments A Residuary-Gratuity equal to the deficiency becomes payable to the family.]
9. The amount of Pension (including ad hoc
increase, if any) drawn by the deceased till
the date of death. [When a Government Servant had retired before earming a Pension, the amount of Service Gratuity should be indicated.]
10. If the deceased had commuted a portion of
portion of Pension before his-death, the commuted
value of the Pension.
11. Total of item 8, 9 and 10
12. Amount of Death-cum-Retirement Gratuity
equal to 12 times of the Emoluments.
13. The Amount of Residuary Gratuity claimed, i.e.
the Difference between the amount shown
against items 12 and item 11.
14. Relationship of the Applicant with the
Deceased Pensioner.
15. Date of Birth of Applicant.
16. Name of the Treasury of Sub-Treasury at
which Payment is desired.
17. Full Address or the Applicant.
18. Signature of thumb - impression of the
Applicant (to be furnished in a separate
sheet, duly attested).
19. Attested by -
Name Full Address - Signature
(i)
(ii)
20. Witness :-
(i)
(ii)
FORM 22
[See Rule 35 (2) (Note (3)]
Form of Medical Certificate
Certificate that I (We) have carefully examined.................... son of................ in the ................. His age by own statement is............... years and by appearance about................ years.
(We) consider.................. to be completely and permanently incapacitated for futher service of any kind in the department to which he belongs in consequence of ............... (here state discase or cause). His incapacity does not appear to me/us to have been caused by irregular or intemperate habits.
Note - (1) If the incapacity is the result of irregular or intemperate habits the following will be substituted for his sentence :-
In my/our opinion his incapacity is directly due to the irregular or intemperate habits/has been accelerated or aggravated by the irregular or in temperate habits.
Note - (2) If the incapacity does not appear to the complate and permanent, the certificate should be modified accordingle and the following addition should be made :-
I am/we are of opinion that.................. is Fit for further service of a less laborious character than that which he had been doing/may, after resting for.............. month, be fit for service of less laborious character than that which had been doing.
| Date........................ |
........................................ (Signature and Designation of Examining Medical Authority) |
Strike out whichever is not applicable.
[Attestation should be done by two Gazetted Goverment Servants or by two or more persons of respectability in the Town, Village or Pargana in which the Applicant Resides.]
FORM 23
[See Rule 45 (4)]
Know All Men by these presents that we
(a) .............................. (b) the widow/son/brother, etc. of (c)................... deceased, resident of ........................ (hereinafter called the Obligor) and (d) ......................... son/wife/ daughter of ...................... resident of.................. the sureties for and on behalf of the obligor (hereinafter called the Sureties) are held and Firemly bound to the Governor of Madhya Pradesh (hereinafte called the Government) in the sum of Rs.....................Rupees.....................) only well and truely to be paid to the Government on demand and without a derur for which payment we bind ourselves and our respective heirs, executors, administrators legal representatives, successors and assigns by these presents.
Signed this ................... day of.....................one thousand nine hundred and................ of the day of 20............
Wheres (c)...................was at the time of his death in the employment of the Government/receiving a pension at the rate of Rs.............. (Rupees............... only) Per month from the Government.
And whereas the said (c)................. died on the day of............ 20........... and there was due to him at the time of his death the sum of Rs................ (Rupees......................) for and towards share of his minor son/daughter in the Deathcum-retirement gratuity.
And whereas the Obligor claims to be entitled to the said sum as defacto guardian of the minor son/daughter of the said (c)............... but has not obtained till the date of these presents the certificate of guardianship from the competent court of law in respect of the said minor (s).
And Wheres the Obligor has satisfied the (c)............... that he/she is entitled to the aforesaid sum and that it would cause undue delay and hardship is the Obligor is required to produce the certificate of guardianship from the competent court of law before payment to him of the said sum of Rs.............
And whereas the Government has no objection the payment of the said sum to the Obligor but under Government Rules and orders, it is, necessary for the Obligor to first execute a bond with one surety/two sureties to indemnify the Government against all claims to the amount so due as aforesaid to the said (c) .......... before the said sum can be paid to the Obligor.
And whereas the Obligor and at his request the surety/sureties have agreed to executive the bond in the terms and manner hereinafter contained.
Now the conditions of this Bond are such that if after payment has been made to the Obligor, the Obligor and/or the surety/sureties shall in the event of a claim, being made byny other person against the (Government with respect to the aforesaid sum of Rs............... refund to the Government the said sum of Rs.............. and shall otherwise indemnifly and keep the Government harmless and indemnified against and from all liabilities in respect of the aforesaid sum and all costs incurred in consequence of the claim thereto. Then the above written bond or obligation shall be void and of no effect but otherwise it shall remain in full force, effect and virtue.
And these presents also witness that liability of the sureties hereunder shall not be impaired or discharged by reason of time being granted by or any forbearance act or omission of the Government whether with or without the knowledge or consent of the surety/sureties in respect of or in relation to the obligations or conditions to be performed or discharged by the Obliges or by any other method or thing whatever which under the law +.................. relating to sureties shall but for this provision, have the effect of so releasing surely/sureties from such liability nor shall it be necessary for the Government to sue the Obligor before suing the surety/sureties either of them the Government agrees to bear the stamp duty, if any, chargeable on these presents.
In witness where of the Obligor and the surety/sureties hereto have set up subscribed their respective hands hereunto on the day and year above written. Signed by the above-named Obligor in the presence of witness :
| 1. ................... | ............................... |
| 2. ................... | Signature of Obligor |
Signature by the above-named Surety-Sureties in the presence of :-
In witness whereof the Obligor and the surety/sureties hereto have set up subscribed their respective hands hereunto on the day and year above written.
Signed by the above-named Obligor in the presence of witness :
| 1. ................... | ............................... |
| 2. ................... | Signature of surety/suretion |
Accepted for and on behalf of the Governor of Madhya Pradesh by............ in the presence of...................
| (Name and designation of witness) | Name and designation of |
| Officer accepting the bond |
Signature of witness :
Note 1. - (a) Full name of the claimant referred to as the "Obligor"
(b) State relationship of the obligor to the deceased.
(c) Name of deceased Government Officer.
(d) Full name or names of the sureties with name or names of the father
(s) husband (s) and place of residence.
(2) Designation of the officer responsible for payment................
Note 2. – The obligor as well as the sureties should have attained majority so that
the bond may have legal effect or force.
FORM 24
[Omitted]
[See Note under Rule 45]
[नियम 45 (1) की नीचे "टिप्पणी निरस्त की गई; म.प्र. शासन वित्त विभाग क्र.एफ.बी.6/5/86/नि-2/चार, दिनांक 15 नवम्बर, 1980 तद्नुसार फार्म नं. 24 Ommitted]
Form of bond of indemnity for drawing of D. C. R. G where there is no nomination or nomination does not subsists.
FORM 25
[See Note below Rule 66]
Deelaration
I (Name)................... was employed in.................... as ................... under the Government of Madhya Pradesh hereby declared that to the best of my knowledge and belief no Goverment dues on account of house rent or water charges in respect of the Government accommodation occupied by me while in the service of Government of Madhya Pradesh are outstanding against me.
Attested ..............................
Signature of Head of Office/Deptt. Signature of retired Govt. Servant.
FORM 26
[See Note below Rule 66]
Undertaking
Wheres I (Name)............... was holding the office of................ under the Government of Madhya Pradesh.
And Wheres I have retired from Government service due to my attaining the age of supernuation on.................. lor in pursuance of the order of Government..............
And whereas the examination and enquiry of the accounts of all moneys to Government including house rent and water charges recoverable from me is likely to take some time.
And whereas the Government have consented to grant me the amount of pension and gratuity due to me for the service rendered by me in anticipation of completion of enquiry to enable the Governemnt to determine the amount of any dues that may be found recoverable from me.
And whereas it is incumbent upon me to pay the amount of said dues found recoverable from me as a result of the said enquiry.
Now, therefore, I hereby, undertake to pay the amount that may be found recoverable from me and in case I fail to pay the same within a period of three months from the date of demand, the said amount may be recovered from me as arrears of land revenue. This undertaking applies only to dues which may be intimated to me within 12 months of my retirement.
| Date | ............................ |
| Witness : | Signature and disgnation. |
| 1............................ | Signed before me. |
| 2............................ | ...................................... |
| Signature and designation |
Form 27
[Inserted vide Govt, of M. P. Finance Deptt. Notification No. F. B. 6/2/80/R-II/IV, dated 1-1-1981.]
[See Rule 29]
Form of certificate of verfication of service for pension
No...............................
Government of M. P.
....................Deptt.
Dated......................
MEMORANDUM
It is certified that Shri.................. (name and designation) has completed a qualifying service of years..................... months and ................... day as on............ (date) as per details given below. The service has been verified on the basis of his service documents and in accordance with the rules regarding qualifying services in force at present.
[The verification done under sub-rules (1) and (2) shall be treated a final and shall not be reopened except when necessiated by a subsequent change in the rules and orders governing the conditions under which the service qualified for pension.] [Inserted vide F. D. Note No. B/6/1/77/R-IIIV, dated 23-3-77 M. P. Rajpatra 4 (Ga), dtd, 6-5-77.]
DETAILS OF QUALIFYING SERVICE
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From
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To
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1.........................
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.......................
|
|
2.........................
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.......................
|
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3.........................
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.......................
|
|
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.......................
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Signature of Head of Office
|
To,
Shri............................
(Name and designation)
FORM 28
[Substituted vide F. D. Notification No. B/6/3/78/R-II/VI, dated 11 September, 1978.]
[See Rule 42 (1) (a)]
To,
.............................
.............................
.............................
Wheres I have complated 20 or 25 years qualifying service and now desire to retire from (Government service under clause (a) of sub-rule (1) of Rule 42 of the M. P. Civil Services (Pension) Rules, 1976, with effect from........................ a notice whereof is hereby given accordingly; [Strike out which are not applicable.]
OR
Whereas, I have complated 20 or 25 years qualifying service and now, desire to retire from Government service under clause (a) of sub-rule (1) of Rule 42 of the M. P. Civil Services (Pension) Rules, 1976, with effect from................ a notice whereof is hereby given accordingly;
and whereas the period of this notice falls short of............... days, the pay and allowances for the days aforesaid have been credited under challan No............ dated............ a copy whereof is enclosed herewith;
Whereas, I have completed 20 or 25 years qualifying service and now desire to retire from Governemnt service under clause (a) of sub-rule (1) of Rule 42 of the M. P. Civil Services (Pension Rules, 1976, forthwith, that is to say from a notice whereof is hereby given accordingly;
The pay and allowances for one month have been credited under challan No................. dated... ...... a copy whereof is enclosed in lieu of one month notice as required by the said cause.
..............................................
Signature and Designation of
the Government servant
[FORM 29]
[Form 29 amended by Notification F. 25-2-2000/PSC/X; dated 30 th May 2000 (M. P. Rajpatra Part IV (Ga) dated 16-6-2000)]
[See Rule 42 (1) (b)]
To,
............................
............................
Whereas, ou have completed 20 years qualifying service/50 years of age on................. And, whereas, with the approval of the State Government, it has been decided in the public interest to retire you from service with effect from................. under clause (b) of sub-rule (1) of Rule 42 of the Madhya Pradesh Civil Services (Pension) Rules, 1976 three months's notice in that behalf is hereby given accordingly. [Strike out which are not applicable.]
Whereas, you have completed 20 years qualifying service/50 years of age on...................... [Strike out which are not applicable.]
2. And, whereas, with the approval of the State Government, it has been decided to retire you in public interest from service with effect from............. under clause (b) of sub-rule (1) of Rule 42 of the Madhya Pradesh Civil Services (Pension) Rules, 1976, a notice of three months in that behalf is hereby given accordingly.
OR
Whereas, you have completed 20 years qualifying service/50 years of age on....................... [Strike out which are not applicable.]
2. Now, therefore, in exercise of the powers conferred by clause (b) of sub-rule (1) of Rule 42 of the Madhya Pradesh Civil Services (Pension) Rules, 1976, with the approval of the State Government you are hereby retired in public interest forthwith without notice that is to say with effect from.........................
Dated...............................
.............................
Appinting Authority.