single comprehensive form automated) of pension for w.b.govt employees

Single Comprehensive Form for Pension Preparation of West Bengal Govt Employees Only

DATA INPUT SHEET

1 Name of the Govt Employee( Block Letters) PANCHANAN MUKHERJEE

2 Designation of the Employee U.D.C.

3 Father's/Husband's Name(Block Letters) LATE- ANANTA MUKHERJEE

4 Name of the recipient of Family Pension(In Block Letters) KALPANA MUKHERJEE

5 Relationship with the Govt Employee Wife

6 Present Address of Employee :-

Village Kalisthanpara P.O. Jiaganj Dist Murshidabad Pin Code 742123

7 Permanent Address of the Employee:-


8 Present Address of the Family Pensioner's(Wife/Husband/Daughter/Son):-


9 Permanent Address of the Family Pensioner's (Wife/Husband/Daughter/Son):-


10 Nationality /Religion of the Govt Employee Indian, Hindu

11 Name & Address of the Office which the employee Last Serve or retire/death :-

Name of Department Land & Land Reforms Department

P.O. Lalbagh Dist. Murshidabad Pin Code 774455

Telephoneno 3483265987 ###

12 Name of the Department of the Retire/death employee Land & Land Reforms Department

13 Employer/PSA'S Number 6254 ###

14 G.P.F Account Number of the Employee ADMN/WB/558899 YearDD MM YY

15 Date of Birth of the Employee 10 8 1949

DD MM YY

Single Comprehensive Form for Pension Preparation of West Bengal Govt Employees Only. Prepared by Pranab Banerjee, Jiaganj, Kalisthanpara, Murshidabad, West Bengal. Email :-

[email protected] OR Cell No.9474316768, 8906279547. This Software Prepared at a time the Single Comprehensive Form + Pension Calculation + Family Pension Calculation + Gratuity

Calculation. Just Put this DATA INPUT SHEET PROPERLY.

Put only the figure in DD/MM/YY

16 Date of Apointment of the Employee 2 4 1969

DD MM YY

17 Date of Retirement of the Employee 31 8 2009

19 Last Pay Band No( Scale No.) 3 Last Pay Band Pay 17190 1/

Last Grade Pay 3900 Last Basic Pay with Grade Pay 21090

Last D.A. Drawn 7382

20 Name of the Treasury/PAO with unit no. i.e. I or II Lalbagh Treasury-I

(where his Residence attached with this T.O.)

21 Name of the Treasury/PAO (with Unit No. i.e. I or I I ) with whichLalbagh Treasury -I

Treasury attached with Employees Office where from he Retired)

21 Name of the Bank Branch (Where the Pensioner drawn his Pension)

United Bank of India, Jiaganj Branch

Bank of Branch BSR Code No. 00555

22 Savings Bank Account No of the Employee 0055226699

(Which Account of Bank is related to Pension) [Enclosed Annexure A in duplicate]

23 Height of the Employee Identification Marks of the employee

5'-3" One Cut Mark on the left feet

24 Details of the Family Members of the Employee:-

Name Date of birth Age Relationship Date of Marriage

1

2

3

4

25 Head of Account to which pension is chargable 2271 - Retirement Benefits

26 Date of applying for Pension/Family Pension 1/7/2008

(The Date will be the just previous One Year from Retirement Date)

28 Whether Commuted Pension wanted Yes

29 Commuted Values for Pension of Re 1 per annum(CVP) 98.328

30 Out standing Amount of House Building Advance if any 0

31 Out standing Amount of Marriage & Illness Advance if any 0

Put only the figure in DD/MM/YY

Marital Status

32 Out standing Amount of Cycle/Scooter/Car/Computer Advance if any 0

33 Out standing Amount of Festival Advance if any 0

34 Any Overdrawal of Pay/Allowances if any 0

SINGLE COMPREHENSIVE FORM

(As per Memo. No. 359-F(Pen) dt. 16.04.2009)

PLEASE FILL IN ALL THE ITEMS PROPERLY AND CAREFULLY. IN CASE A PARTICULAR

ITEM IS NOT APPLICABLE, PLEASE STATE SO. BUT DO NOT LEAVE THE ITEM BLANK. THIS FORM

NOT COMPLETED IN ALL RESPECTS WILL NOT BE ACCEPTED AND A FRESH SINGLE

COMPREHENSIVE FORM MAY BE CALLED FOR.

1 Name of the Govt. employeePANCHANAN MUKHERJEE

(IN BLOCK LETTERS)

2 Designation of the Govt. employee U.D.C.

3 Father’s/Husband’s Name of the Govt.LATE- ANANTA MUKHERJEE

employee

4 a Name of the recipient of family pension (INKALPANA MUKHERJEE

BLOCK LETTERS )

b Relationship with Govt. employee Wife

5 Address of the Govt. employee :

a Present Vill Kalisthanpara P.O. Jiaganj

District Murshidabad Pin Code 742123

b Permanent Vill Kalisthanpara P.O. Jiaganj


6 Address of the family pensioner (in case of death while in service/after retirement)

a Present Vill Kalisthanpara P.O. Jiaganj


b Permanent Vill Kalisthanpara P.O. Jiaganj


7 Nationality and Religion Indian, Hindu

8 a Name of the establishment last served/serving Land & Land Reforms Department

with full Address and Telephone No. / FAX No. P.O. Lalbagh Telph.No 3483265987


b Name of the Department Land & Land Reforms Department

9 Employer / PSA’s code No. 6254

### Status of the Govt. employee Permanent

(Temporary/Permanent)

b b. Whether work-charged employee Nil

c Whether appointment is made on ad-hoc basisNoand if so, whether regularised subsequently

(enclose copy of Govt. order)

### Whether a member of General Provident FundADMN/WB/558899

(GPF), if so quote GPF Account No

### If anytime whether he was a member ofNOContributory Provident Fund (CPF), If so, quote

CPF Account No.

### If he was a member of Contributory Provident

No

Fund (CPF), whether the employer’s share ofCPF along with interest and additional interestaccrued thereon has been credited to the Govt.

Account (with full particulars mentioning the

No

period for which refund made)

### Pension Rules and relevant Govt. order Rule 57 of DCRB Rules 1971

applicable in this case

### Class of Pension applicable Superannuation

(i.e. Superannuation /Family / Retiring / InvalidProrata/ Compensation etc)

### Govt. / Non-Govt. organisation under which

NILservice has been rendered (in order ofemployment & showing the periods servedunder each govt.)

### a Date of Birth of the Govt. employee ( by Day Month Year

Christian era) 10 8 1949

b Date of appointment 2 4 1969

c Date of Retirement 31 8 2009

d Period of gross service 40 Years 4 Months 29 Days

e Period of war/military service, if any NIL

f Details of period(s) of Service on deputation Orgination From To Remarks

terms to Govt.unertakings/Autonomus bodies/ NIL NIL NIL NIL NILLocal bodies etc.

g Amount and nature of Pension/Gratuity NIL

Received for Military service

h Whether opted for Family Pension NOon account of Military Service

### Non-qualifying service :

a EOL without medical certificate NIL

b Period of suspension not to beNIL

counted towards pension etc.

c Other non qualifying service, if any NIL

### Net qualifying service (Gross service minus Years Month Dayi.e. 33 Years

non-qualifying service 40 4 29

### Weightage of Service admissible, if any.

Does not arise(Employee retired on or after 25/02/2009, the benefit of weightage under rule 27 of WBS

(DCRB)Rules, 1971 is not applicable)### Total service qualifying for

33 Yearspensionary benefits (19+20).

a Last pay drawn with scale of pay Pay Band No 3 Pay Band Pay 17190

Grade Pay 3900 Basic Pay 17190

b Proposed Superannuation

Rs. 10545Pension/Retiring Pension / Invalid

Pension/Pro-ratapension/Compensation Pension.

c ProposedRetiring Gratuity/DeathRs. 469,788

Gratuity

d Proposed family pension, if Rs 10545 Up to 30 7 2016

applicable Thereafter Rs. 6327

### Date on which the Govt.1/7/2008

Contribution Received

employee/family pensioner applied 1/7/2008

for pension

### Date from which pension/family 1/9/2009pension is to commence

a Whether commutation of pensionYes

wanted?

b If so, amount/portion of pension to

be commuted

c Date on which application for1/9/2009commutation has been received by

the pension sanctioning authority

d Proposed amount of ReducedRs. 4218Pension ( in case of commutation

applied and sanctioned)

e Proposed amount of CVPRs. 414,748 (enclose applicat ion for commutation

in prescribed form duly accepted by( PSA)

### Place of payment of Pension /Family Pension

Lalbagh Treasury-I(State clearly the name of Treasurywith Unit No. i.e. I or II if payment is

desired in West Bengal.)

### Name of the Treasury / PAO (withLalbagh Treasury -IUnit No. i.e. I or II) with which

Pension Sanctioning Authority attached

### Whether payment of pension /family pension is desired through a Public Sector Bank within

the jurisdiction of Kolkata Corporation area, If so,

a Name of the Bank & Branch Name of the Bank of Branch B.S.R. CODE NO

(with B.S.R. Code No. of the Paying Branch as United Bank of India, Jiaganj Branch 00555as well as Link Branch)

b S/B A/c. No. (in single name /joint name) 0055226699(Enclose Annexure A in duplicate)

### Descriptive Roll of the pensioner/family pensioner(enclose descriptive roll in 3 separate

sheets with the following information) :

(i) Height 5'-3"

(ii) Identification marks One Cut Mark on the left feet

(ii) Left Thumb and finger impression Thum Fore finger Middle finger Ring finger little finger

THUMB FORE FINGER MIDDLE FINGER RING FINGER LITTLE FINGER

(Persons who are literate enough to sign their names in English, Hindi or the Official Regional

Language, are exempted from recording their left thumb and finger impressions)

### Statement of family members (including unmarried / widowed

/divorced daughter beyond 25 years & physically crippled and mentally retarded son/daughterbeyond 25 years)

Sl No Name(s) Date of birth Age Matrital Status

1 - - - - - ###

Relationship with category

Date of Marriage

2 - - - - - ###

3 - - - - - ###

4 - - - - - ###

###Whether nomination made for LTA/ Family Pension Yes

b If so, state the name of the nominee

(enclose the nomination paper in duplicate) KALPANA MUKHERJEE

c If not, state the name(s) of the legal heir(s),

his/her/their age, share payable and relationship Does not Arisewith the deceased pensioner/family pensionerwhere LTA of pensionary benefits are payable.

### (For Death cases only)

Noa Whether nomination made for death-gratuity

(Yes/No)

b If so, state the name (s) of the nominee (s),

Does not Arisehis/her/their relationship with the Govt.

employee and share payable

(Enclose two copies of the duly accepted nomination form - one in Service Book and other

with pension papers )

c State below the details of surviving family members [Defined in Rule 7(1) of the W.B.S.(DCRB) Rules, 1971

Statement of the Family Members

Name(s) Age

1 - - - - - 12/30/1899

2 - - - - - 12/30/1899

3 - - - - - 12/30/1899

4 - - - - - 12/30/1899

N.B. :

Daughters married before death of Govt. employee do not fall in the definition of Family for thepurpose of Death Gratuity.

### Outstanding dues of the Govt. employee

a House Building Advance 0

b Marriage & Illness Advance 0

c Cycle /Scooter/Car Advance/Computer Advance 0

d Festival Advance 0

e Overdrawal of pay/allowances , if any, with the0

Head of Account under which it is to be credited

f Any other outstanding dues with H ead ofNil

Account under which it is to be credited

### a Provisional Pension/Family Pension paid,Nil(Please state the rate and the period for which

if any paid)

Sl. No

Date of Birth

Relationship with category

Matrital Status

Date of marriage in case of married daughters

included, if any

b Provisional gratuity/death gratuity paid, if any Nil

c Interim relief paid, if any Nil

### Head of Account to which pension/gratuity is 2271 - Retirement Benefits

chargeable

### a Whether the Govt. employee is Nore-employed afterretirement

b If so, details of re-employment and fixation of Nore-employed pay may be stated with necessary

order of competent authority.

### a Whether the family pensioner is employedNo

(widow/widower) .

b Whether the Family Pensioner is in receipt of

Noany other Pension/Family Pension. If so, details

thereof.

### Please state the name of legal guardian who

Does not arisewill draw the share of LTA pension/family

Pension /gratuity/death gratuity in favour of minors.

### Whether any vigilance case/court

Nilcase/departmental or criminal proceedings ispending against the Govt. employee. If so, givedetails with supporting documents.

### Any other Remarks No

###(A) The undersigned having satisfied himself that the above particulars are true and that the service

of the Govt. employee has been thoroughly satisfactory hereby orders the grant of the full

pension/family pension, death-cum -retirement gratuity which may be accepted by the Accountant

General & as admissible under the rules. Or

(B) The undersigned having satisfied himself that the service of Shri/Shrimati/Kumari------------

KALPANA MUKHERJEE has not been throughly satisfactory

here by orders that the full pension/family pension/death-cum-retirement gratuity, which may be

accepted by the Accountant General & as admissible under the rules shall be reduced by the specified

amount or percentage indicted below:-

Amount or percentage of reduction pension/family pension--------------------------------------

Amount or percentage of reduction in gratuity-------------------------------------------. The grant of

pension/family pension, death-cum-retirement gratuity -------------------------------------------------------.

(Inapplicable portion should be scored out)

This order is subject to the condition that if the amount of pension and/or gratuity as authorised

be afterwards found to be in excess of amounts to which the pensioner is entitled under the rules,

he/she shall remain liable to refund such excess.

Dated :

Signature

Full Name

Designation of the

Pension Sanctioning Authority

Form ANomination for Death Gratuity

(When the Government Servant has a family and wishes to nominate on member thereof)

I hereby nominate the person mentioned below who is a member of my family, and fonfer on him

the right to receive any gratuity that may be sanctioned by Government in the emvent of my death while in

service and the right to receive on my death any gratuity which having become admisible to me on

retirement may remain unpaid at my death

Age

KALPANA MUKHERJEE

0 0 Divorce or Insanity

Vill Kalisthanpara

100%Vill Kalisthanpara P.O. Jiaganj

P.0. Jiaganj Dist Murshidabad

Dist Murshidabad Pin Code 742123

This nomination supersedes the nomination made by me earlier…………………. Nil……………which

stands cancelled.

Dated this…………………. Day of………………… 20……………..at office of the ………………………………

……………………………………………………………………………..

Witness to signature:-

1…………………………………………………………….

2……………………………………………………………

Signature of the Employee

Note:- The last column should be filled in to cover the whole amount of Gratuity( to be filled in by the Head of office in the case of Non-Gazetted Officer)

Nominated By :

Designation :

Department Signature of the Head of Officer with Seal

Name and Address of Nominee

Relationship with Officer

Contigencies on the happening of which

the nomination shall be come

invalid

Name and address and relationship of the person or persons if any, to whom the

right conferred on the nominee shall pass in the event of the nominee predeceasing the

officer or the nominee dying after the death of the officer

but before receiving payment of the gratuity

Amount or share

of gratuity

Form C(to be submitted in duplicate)

PART-I[Rule 14(1)(a)]

Form of application for Commutation of Pension whthout Medical Examination

I furnish below the relevant particulars and request that may be permitted to commute a portion

of my Pension as indicated below:-

1 Name (In Block Letters) PANCHANAN MUKHERJEE

2 Date of Birth 1/9/1900

3 Date of superannuation on attaining the 31

age of 60 years)

4 Designation of the post held at the time of U.D.C.Superannuation and the name of the

Department/Office

5 Amount of pension sactioned and whetherNot Yet Sanctioned

it is provisional or final

6 Class of pension as defined in the

SuperannuationWest Bengal Service(Death-cum-Retirement

Benefit) Rules, 1971

7 Name of the Treasury or Bank and AccountLalbagh Treasury-I

Number from which pension is being drawn

8 Name of the Treasury or Bank through which

Lalbagh Treasury-Ithe commuted value is desired to be paid,ifpayment is not desired through the AccountsOfficer who authorised the pension

9 Designation of the Accounts Officer and the A.G.West BengalNunmber and date of the Pension Payment

Order, if issued:

10 Amount( in whole rupees) of pension and 40% of my Pension i.e. Rs. 0

protion of pension proposed to be commuted

11 Particulars of any application for commutationNilof pension made previously and whether

appeared before any Medical Authority or not

Dated:-Signature of the Applicant with Full Address

Accepted

single comprehensive form automated) of pension for w.b.govt employees

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