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17. Qualifying Service:(a) Details of commission,imperfection of deficiencies in theservice book which have beenignored under rule 59(1)(b)(ii)(b) Period not counting as qualifyingservices:(i) Boy service (2 nd Proviso to rule13)(ii) Extraordinary leave notcounting as qualifying service(rule 21)(iii) Periods of suspension nottreated as qualifying service(rule 23)(iv) Interruption in service rule27(1)(b) and rule 28(c)(v) Periods of Foreign service withUnited National Bodies forwhich United Nations Pensionshas been availed(vi) Any other period not treated asqualifying service (give details)(c) Addtions to qualifying service:(i) Military Services (rule 19)(ii) War service (rule 20)(iii) Weightage on voluntaryretirement on being declaredsurplus (rule 29)(iv) Weightage under rule 30(v) Benefit of service in anautonomous body (rule 37)(vi) Weightage under rule 48-B(d) Net qualifying service(d) Qualifying service expressed interms of completed six monthlyperiods (period of three months andover is treated as completed sixmonthly period)

18. Emoluments:(a) Emoluments drawn during 10 months preceeding retirement.From To Rate of Pay Amount(Total)(b) If the Officer was on foreign serviceimmediately preceding retirement, thenotional emoluments which he wouldhave drawn under Govt. but for beingon foreign serviceAverage Emoluments:(c) Average emoluments reckoned forpension(d) Emoluments reckoned for retirementgratuity/death gratuity(e) Emoluments reckoned for FamilyPension -19. Date on which the retiringemployees submitted his applicationfor pension in Form-520. Complete and up-to-date details ofthe Family as given in Form-3Sl. Name of the member of the Date of Birth Relation with theNo. family Government servant

28. Name and address of Bank/PensionAccounting Office from wherePension is to be drawn29. Head of Account to which pensionand gratuity are debitable30. Post retirement address of the retireePlace:Date:

PROFORMAParticulars to be obtained by the Head of Office from the retiringGovernment Servant1) Name of the Govt.servant2) a) Date of Birth :b) Date of Retirement :3) Two Specimen signature (to befurnished in two separate sheets)Duly attested by a GazettedGovernment Servant4) Three copies of Pass Port sizejoint photograph with wife,husband (to be attested by aGazetted Government Servant)5) Two slips showing theparticulars of height andpersonal Identification marksduly attested by the GazettedGovernment Servant6) Present Address7) Address after retirement\8) Name of the Treasury /PublicSector Bank through which theGovt.servants wants to draw hispension9) Details of the Family in Form 310) Indicate whether Family Pensionis admissible from any othersource – Military or State Govt.and/or a Public SectorUndertaking/AutonomousBody/Local Fund under theCentral or a State GovernmentPlace:Date:

FORM – 3(See Rule 54(12)1. Name of the Government Servant2. Designation3. Date of Birth4. Date of AppointmentDetails of the Members of FamilySl.No.1Name of the Members ofFamilyRelationship toGovt. ServantDate of BirthRemarks23I hereby undertake to keep the above particulars upto date by notifying to theAudit Officer/Head of Office any addition or alteration.Place:Date:

DECLARATIONI, hereby declare that should the amounts ofSuperannuation/Family Pension and Death-cum-Retirement Gratuity paid to me by theGovernment be afterwards found to be in excess of the amount to which I am entitled tounder the Rules, I am willing to refund such excess amount, later on, when called upon todo so.Place:Date:

HEIGHT AND PERSONAL IDENTIFICATION MARKS OFDesignation:Place:1. Height:2. Personal IdentificationmarksATTESTED

SPECIMEN SIGNATURES OF SRI. ...........................................................Designation:Place:1.2.3.ATTESTED

JOINT PHOTOGRAPH OF SHRI ...................................................Designation:Place:Paste the Joint photographAttested

STATEMENT OF CALCULATION OF PENSION AND DCRG INRESPECT OF SHRI1(a) Qualifying service (from 23.4.1967to 6.7.73 and from 7.7.1973 to30.6.2005)(b) Weightage given under Rule 48B(1)(c) Total Qualifying Service2. Interruption in Service3. Extraordinary leave not counting forPension4. No.of completed six monthly period5. Average Emoluments for thepurpose of pension6. Emoluments for the purpose ofDCRG(Last Pay drawn + DA @ 50%)7. DCRG Gratuity Admissible:(a) Gross amount of DCRGadmissible(b) Govt dues, if any, to beadjusted from DCRG(c) Amount of DCRG to bewithheld in case surety bond isnot furnished(d) Net amount of DCRG payable8. (a) Retiring Pension(b) Relief on pension9. Family Pension(a) Enhanced Rate(b) Normal RateDUE TO RETIRE ONYears Months Days.Place:Date:

FORM – 1A(See rules 5(2), 12, 13(3), 14(1) and 15(3)FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OFSUPERANNUATION PENSION WITHOUT MEDICAL EXAMINATIONWHEN APPLICANT DESIRES THAT THE PAYMENT OF THECOMMUTED VALUE OF PENSION SHOULD BE AUTHORISEDTHROUGH THE PENSION PAYMENT ORDER.(To be submitted in duplicate atleast three months before the date of retirement)ToThe Chief Secretary toGovt. of Karnataka,Bangalore.Part-1Sir,Subject: Commutation of Pension without Medical Examination.-----I desire to commute a fraction of my pension in accordance with the provisions ofthe AIS (Commutation of Pension) Rules, 1981. The necessary particulars are furnishedbelow:1. Name in Block Letters2. Father’s Name (and also husband’sname in the case of a femaleGovernment servant)3. Designation4. Name of Office/Department /Ministry in which posted5. Date of Birth6. Date of retirement onsuperannuation or on the expiry ofextension in service7. Fraction of superannuation pensionproposed to be commuted(Maximum amount of pension thatcan be commuted is 40%)

8. Disbursing authority from whichpension is to be drawn afterretirement:(a) Treasury/Sub-Treasury(Name and complete address ofthe Treasury to be indicated)(b) (I) Branch of the nominatedNationalised bank withcomplete postal address:(ii) Bank Account No. to whichmonthly pension is to becredited each month:(c) Accounts office of the Ministry/Deptt/Office:Place:Date:Present Postal Address:Postal Address :After Retirement.

PART-IIReceived from Shriapplication in Part-I of form D forcommutation of fraction of pension without medical examination.Place: BangaloreDate:SignatureHead of OfficePart-IIIForwarded to the Accountant General in Karnataka, Bangalore with theremarks that:(i)(ii)(iii)(iv)The particulars furnished by the applicant in Part-I have beenverified and are correct;The applicant is eligible to get a fraction of his pension commutedwithout medical examination; andThe commuted value of pension determined with reference to theTable applicable at present comes to Rs.9,18,216/-, andThe amount of residuary pension after commutation will beRs.11,700/- p.m.2. The pension papers of the applicant completed in all respects wereforwarded under this Ministry/Dept/Office letter No.dated. It is requested that the payment of commuted value ofpension may be authorised through the Pension Payment Order which may beissued one month before the retirement of the applicant.3. The receipt of Part-I of this Form has been acknowledged in Part-II whichhas been forwarded separately to the applicant on4. The commuted value of pension is debitable to Head of AccountPlace: BangaloreDate:Under Secretary to Government,D.P.A.R.(Services-I)

GOVERNMENT OF KARNATAKANo. DPAR SAS 2003 Karnataka Government SecretariatVidhana SoudhaBangalore, Dated: .From:To:Sir,The Chief Secretary toGovernment of KarnatakaBANGALORE.The ManagerState Bank of MysorePersonal Banking BranchK.G. Road,Bangalore-560 009.This is to certify that Sri. ............................................ who retired onthe afternoon of ............................ has received the following pensionarybenefits:G.P.F. … Rs.DCRG … Rs.Commutation … Rs.Earned LeaveEncashment … Rs.-----------------TotalRs.-----------------Yours faithfully,Under Secretary to GovernmentDP&AR(Services-I)