Form 1-A - Form Of Application For Commutation Of A Fraction Of Superannuation Pension Without Medical Examination Page 2

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(a)
Treasury/Sub-Treasury (Name and
complete address of the Treasury/Sub-
Treasury to be indicated)
(b)
(i) Branch of the nominated nationalized
bank with complete postal address
(ii) Bank Account No. to which monthly
pension is to be credited each month
(c)
Account Office of the
Ministry/Department/Office
Signature
Present Postal address.
Postal address after retirement.
Place :
Date :
Footnote : 1. The applicant should indicate the fraction of the amount of monthly pension (subject to a
maximum of one-third thereof) which he/she desires to commute and not the amount in rupees.
2. Score out which is not applicable.
PART II
(ACKNOWLEDGEMENT)
Received from
Shri/Smt./Kumari
(name)
(designation)
application in Part I of Form I-A for commutation of a fraction of pension without medical examination.
Place :
Signature
Date :
Head of Office
NOTE. - If the application has been received by the Head of Office before the date of retirement on
superannuation, this acknowledgement should be detached from the Form and handed over to the
applicant. If the form has been received by post, it has to be acknowledged on the same day and the
acknowledgement sent under registered cover to the applicant. In case it is received after the specified
date, it should be accepted only if it has been put into the post on or before that date subject to the
production of evidence to that effect by the applicant.

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