Form I - Form Of Application For Commutation Of A Percentage Of Pension Without Medical Examination
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1
2FORM I
FORM OF APPLICATION FOR COMMUTATION OF A
PERCENTAGE OF PENSION WITHOUT MEDICAL EXAMINATION
(To be submitted in duplicate after retirement but within one year
of the date of retirement)
PART I
To
The...................................................
.........................................................
.........................................................
(Here indicate the designation and full address of the Head of Office
Subject:- Commutation of pension without medical examination.
Sir,
I desire to commute a percentage of my pension as indicated below in accordance with the
provisions of the Central Civil Services (Commutation of Pension) Rules, 1981. The necessary
particulars are furnished below -
1. Name (in Block Letters)
... ... ...
2. Father's name (also husband's name in the case
of a female Government servant)
... ... ...
3. Designation at the time of retirement
... ... ...
4. Name of Office/Department/Ministry in which
... ... ...
employed
5. Date of birth (by Christian era)
... ... ...
6. Date of retirement
... ... ...
7. Class of pension on which retired
... ... ...
8. Amount of pension authorized. [In case final
amount of pension has not been authorized,
indicate the amount of provisional pension
sanction under Rule 64 of the Central Civil
... ... ...
Services (Pension) Rules, 1972]
*
9.
Percentage of pension proposed to be
... ... ...
commuted
10. Designation of the Accounts Officer who
... ... ...
authorized the pension and the No. and date of
the Pension Payment Order, if issued
1
11.
Disbursing authority for payment of pension -
(a) Treasury/Sub-Treasury (Name and
... ... ...
complete address of the Treasury/Sub-
Treasury to be indicated)
(b) (i) Branch of the Nationalized Bank with
complete postal address
... ... ...
(ii) Bank Account No. to which monthly
pension is being credited each month
... ... ...
(c) Accounts Office of the
... ... ...
Ministry/Department/Office
21
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