By Ellen Shaw,2014-05-07 15:31
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    [RULE 57(1), 59,61(1), 63(1) AND (7)]


    1.Name of the Government Servant: -----------------------------

    2.Father’s Name (and also Husband’s Name

     in the case of female Government Servant -------------------------------

    3.Date of Birth (by Christian era) -------------------------------

    4.Religion and nationality ------------------------------

    5.Permanent residential address showing

    Village/Town, District and State: ------------------------------

    6.Present or last appointment including name of

     Establishment ------------------------------

    7.Date of beginning of Service: ------------------------------

    8.Date of ending of Service: ------------------------------

    9. (i) Total period of military service for which

     pension/gratuity was sanctioned. ------------------------------

     (ii) Amount and nature of any pension /gratuity

     received for the military Service. -------------------------------

    10.Amount and nature of any pension/gratuity

     received for previous civil service. -------------------------------

    11.Government under which service has been

     rendered in order of employment . --------------------------------

    12.Interruption and non-qualifying service. --------------------------------

    13.Length of qualifying service. --------------------------------

    14.Class of pension or service gratuity applied

     for by The Government servant and cause

     of application. ---------------------------------

     (In case of invalid pension, medical certificate

     to be attached.)

    15.Whether the Government servant is a pre 1933 ------------------------------

     Entrant and Sub-rule (2) of rule 40 of M.P.Civil Services

     (Pension) rule 1976 applies to him.(in respect of

     Allocated employees of Former M.P. only) .

    16.Emoluments reckoning for gratuity: ------------------------------ 17.Average emoluments reckoning for pension:

    18.Proposed Pension: -------------------------------

    19 Proposed death-cum-retirement gratuity ------------------------------- 20.Proposed service gratuity, if any. ------------------------------- 21.Date from which Pension is to Commence. --------------------------------

    22.Whether nomination made for: --------------------------------

     (i)Death cum retirement gratuity.

     (ii)Non-contributory family pension if applicable.

     23.Whether Government Servant has paid all the

     Government dues: ------------------------------- 24.Wheather the contributory family pension applies to

     The government servant and if so: -------------------------------

     (i)Emoluments reckoning for contributory family pension

     (ii)The amount of contribution to be recovered out of gratuity.

     (iii)The amount of contributory family pension becoming

     payable to the wife husband of the Government servant in

     the event of his /her death after retirement-

     at enhanced rate of ------ From ----To ----------

     at normal rate of ------ From ----To ----------

     (iv)Complete and up to date details of family as given in form 3: -


     S.No Name of the member of the family Date of birth Relationship with Govt.


    1 2 3 4




    3. 4. _____________________________________________________________

    25. Height: ------------------------------

    26.Identification mark: - -------------------------------

27.Place of payment of pension/ gratuity -------------------------------

     (Treasury or Sub Treasury).

     27-A Name and place of branch of -------------------------------

     Public sector bank if pension or

     gratuity is desired to be drawn

     through it.

28.Head of Account to which pension and gratuity……………..are debetable.

Place: …………………………

Dated the :----- Signature of Head of Office

    PART - II


     Emoluments drawn during the last 10 month of service


     Post held From To Pay Personal Special Pay

     1 2 3 4 5



     Average Emoluments


     Details of non-qualifying Service

1.Interruption (s) Y. M. D From To

    2. Any other services not treated as qualifying:

     Total: -

     Section III

1.Period of services not verified with reference to_____________________________

     acquittance Rools.

    2.Whether the above period has been verified

     in Accordance with the provisions of rule 58

     of M.P .Civil Service (Pension) Rule 1976.._____________________________

    Section IV

     (To be used by the head of office for grant of anticipatory /provisional pension /gratuity )

     Details of anticipatory or provisional pension and gratuity to be drawn and disbursed by the head

    of office in accordance with the provisions of rule 61 and 64.

     Pension Rs.---- -p.m.

     Gratuity Rs. ----

     (a).Contribution towards contributory family pension

     If applicable Rs. ----

     [See item 24(ii) of part 1]

     (b).Government dues which have been ascertained

     And assessed. Rs.----.

    (c).Amount of gratuity held over for adjustment of

     Government dues which have not been assessed so far Rs.----.

    (d).Total of (a) , (b) and (c) Rs.----


     Net Amount of anticipatory / provisional gratuity payable Rs………



    Section I

Audit enfacement

1.Total period of qualifying services which has been accepted for the grant of

     superannuaton/ retiring/ invalid/compensations/Compulsory retirement pension/gratuity

     with reasons for disallowance if any.

     NOTE: Service for the period commencing from-------------- --up to date of retirement

     has not yet been verified; this would be done before the pension payment order is issued.

2. Amount of superannuation/retiring/invalid /compensation/compulsory retirement pension/

     gratuity that has been admitted.

3. Amount of superannuation/retiring/invalid/compensation/ compulsory retirement

     pension/gratuity , admissible after taking into account reduction, if any, in pension and

     gratuity made by the pension sanctioning authority.

4. The date from which superannuation /retiring /invalid /compensation/compulsory retirement

     pension/gratuity is admissible.

5. Head of account to which superannuation /retiring/invalid/compensation /compulsory

     retirement pension / gratuity is chargeable.

    6. The amount contributory family pension becoming payable to the entitled members of the

     family in the event of death of Govt. Servant after retirement.

At enhanced rate of _____________________p.m. from----------- to---------------

At normal rate of _______________________ p.m. from------------to---------------

     Account Officer

     Assistant Accountant General



1. Name of the Government Servant. ___________

    2. Class of pension or gratuity. ___________

    3. Amount of pension sanctioned. ___________

    4. Amount of gratuity sanctioned. ___________

    5. Date of commencement of pension. ____________

    6. Amount of contributory family pension ____________

     admissible in the event of the death of the

     Govt.Servent after retirement:

     At enhanced rate_______________________.

     at normal rate_________________________. 7. Amount recoverable from gratuity under sub

     rule 2(b) of rule 65 of the M.P. Civil Services

     (pension) rules ,1976. ______________

    8. The amount of cash deposit or the amount of

     gratuity held over for adjustment of unassessed

     Government dues. _______________



    1. AVERAGE EMOLUMENTS- The calculation of average emoluments mentioned in item 17,

    of Part-I Should be based on the actual number of days contained in each month.

    2.Compensation Pension Or Gratuity

    (a) If the case is of a compensation pension or gratuity the particulars of the savings affected

    should be fully stated against item 14 of Part I of this Form.

    (b) State why employment was not found elsewhere.

     3.Details Of Services-All period not reckoned, as service should be distinguished.

     4.Identification Marks-Specify a few conspicuous mark, not less then two, if possible.

     5.Name-When initials or name of the Government Servant are or is incorrectly given

     in the various records consulted, mention this fact in the letter forwarding the pension


     6.Date of retirement-Date of retirement to be indicated in the service book and the last

     pay Certificate, if any .

     7.Reinstatement-In the case of a Government Servant who has been reinstated after having been

     suspended, compulsorily retired, removed or dismissed from service, brief statement leading to

     his reinstatement should be appended.

     8.Alterations- Alterations to be made in red ink under dated initials of a gazetted Government



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