PÁ ÉÃdÄ ²PÀët E ÁSÉUÉ ¸ÀA§A¢ü¹zÀ ¸ÀPÁðj C¢ü¸ÀÆZÀ£É : DzÉà ...

- 197 -INSTITUTIONCOUNTERSIGNEDDeclaration Regarding Non Receipt of Government Share of Contribution Under Triple BenefitSchemeI hereby declare that I have neither applied for nor received any Government share ofcontribution under the Triple Benefit Scheme in respect of any portion of my service qualifying forthis pension and gratuity nor shall I submit an application for the same hereafter.Station:____________________Date:__________________200Signature ofEmployee:______________________Designation:Institution:"COUNTERSIGNED"Undertaking By the Official To Refund The Amount of Pension / D.C.R.G., If Found To BeExessive Subsequently.I hereby undertake to refund the amount of Pension and / or Gratuity to be sanctioned to me ifany portion of the same found to be exessive subsequently.Station:____________________Date:__________________200Signature ofEmployee:______________________Designation:Institution:"COUNTERSIGNED"DECLARATION REGARDING NON-PENDENCY OF ENQUIIRYI here by declare that No Judiciary/ Departmental enquiry is Pending against me as on thisday__ ______________________________________________________Station:____________________Date:__________________200Signature ofEmployee:______________________Designation:Institution:"COUNTERSIGNED"1. Name of the Government ServantFORM "D"Form for sanctioning Family Pension2. Father's name (and also husband's name in the case of awoman Government servant)3. Religion and Nationality4. Last appointment held including name of establishment5. Date of beginning of service6. Date of ending service