1.
I have received Rs. ------ P. ----------- being my pension for
--------------------------------
(Month
& Year)
2.
Please hand it over to
--------------------------------------------------------------
(Nominee’s
Name, Rank or Designation)
whose
specimen signature/left hand thumb Impression is given below.
3. Signature or left-hand thumb impression
of Pension. (On One Rupee stamp if the
amount exceeds Rs. 500. Non-commissioned Officers and men and their heirs
are exempted.)
Specimen
Signature Left-hand
Station ----------------------
Thumb
impression of the Nominee
Dated -----------------------
|
DECLARATION (A) I
declare that I have not received pay or allowances for serving in (a) any
military capacity, (b) on re-enrolment or re attestation during the period
for which pension is claimed on the basis of this certificate or during
any period since the last declaration was given by me (see notes 1 to 3
and 5 below) --------------------------- Signature or left-hand thumb impression of the
pensioner Station
------------------- Dated
------------------- |
DECLARATION
(B) I
further declare that except the pension specified in the certificate, I am
neither in receipt of any family pension nor any service or disability
pension in respect of previous service in any regiment or other Military
formation or any other Department, Civil or Military under Government of
India or any Local Government (see Notes 1 to 3 below) --------------------------- Signature
or left-hand thumb impression of the pensioner Station
------------------- Dated
------------------- |
DECLARATION
(C) I
declare that I am in receipt of a second pension, full particulars of
which are given below 1.Nature
of Pension------------------------------ 2.
Rate of Pension--------------------------------- 3.Date
of commencement of Pension ------------------ 4.Service
or other particulars in respect of which the second pension was granted
------------------------------- 5.
Authority sanctioning the second Pension --------- --------------------------- Signature
or left-hand thumb impression of the pensioner Station
------------------- Dated
------------------- |
NOTE:
1.
When a pensioner is neither re-employed nor in receipt of a second
pension he should sign at the place provided for the purpose underneath the
Declaration ‘A’ & ‘B’.
When
a Pensioner is re-employed, he would sign at the place provided for the purpose
underneath the Declaration ‘B’ as well as I.A.F.A. 379, which will be in
lieu of Declaration ’A’.
When
a Pensioner is in receipt of a second pension, he should sign at the place
provided for the purpose underneath the Declaration ‘A’, further information
regarding the second pension should be recorded in Declaration ‘C’.
Female
pensioners applying for pensions whose pensions are terminable by re-marriage,
or marriage, should render a widowhood or non-marriage certificate in addition.
Declaration
‘A’ is not applicable in the case of a female family pensioner.
FOR USE BY THE PENSIONER’S NOMINEE
I
have received Rs. ------------------ being pension cf
--------------------------------------------------------------------
(Descriptive No. Rank and Name of the Pensioner) to be handed over to him/her.
Station
--------------------
Nominee’s Signature ------------------------
Dated
---------------------
Rank or Designation -----------------------
FOR USE BY THE ATTESTING OFFICER
I
hereby certify that pensioner -------------------------------------------------
(Descriptive
No. Rank and Name)
late
of the ------------------------------------------------------------------------
(Corps.
Department or Office)
Or
pensioner’s heir or heirs
--------------------------------------------------------
(Descriptive
No. and Name)
being
widow or children of late --------------------------------------------------
(Rank, Name and Corps or Office)
is
or are alive on this date and I his/her signature or left-hand
thumb impression on this form have been taken in my presence.
Station
--------------------
Nominee’s Signature ------------------------
Dated
---------------------
Rank or Designation -----------------------
Signature
or left-hand thumb
impression
of the pensioner
NOTE:
1.
Life Certificate should be obtained on or after the last day of the month
or quarter for which pension is due.
In
the case of severely wounded and infirm Indian Military pensioners and female
pensioners who are not accustomed to appear in public, a life certificate from a
responsible Govt. Officer or by
some other well-known and trustworthy person will be accepted. A certificate
issued by a Junior Commissioned Officer/Junior Commissioned officer pensioner, a
retired Gazetted officer pensioner, a Sub- Inspector of Police, a Sub-
Postmaster, a Tehsildar, a Village Head Man, a Patti Patwari (in the case of
Garhwali pensioners) or the head of the Village Panchayat, who is acquainted
with the pensioner will also be accepted by the Pension Disbursing Officer,
provided he has no reason to doubt the veracity of such a Certificate.
In
the case of Gorkha pensioner living in Nepal who is physically unable to apply
for his pension in person, payment may be made through a Pension Disbursing
Officer in India or under arrangements by the Indian Embassy Nepal, to a
representative who produces a life certificate signed by other two male military
pensioners if below J.C.O. rank or by a pension of J.C.O. rank acquainted with
the pensioner.
In
the case of pensioners residing in Sikkim and Bhutan who are physically unable
to draw their pensions in person, payment may be made by the Political Officer
there, through a representative in accordance with procedure indicated in Note 3
above.