Form
for Nomination for claiming arrear:
To
be filled by the pensioner during his life time
(FORM-A)(See rule 5)
Pension
Disbursing Authority/Head of Office
(Name
of Bank/Treasury/Post Office/Accounts officer etc.)
(Place)
---------------------------------------
I,
--------------------------------------------- hereby nominate the person
(Name
of the pensioner in capital letters)
Named
below under rule 5 of the payment of Arrears of Pension (Nomination) Rules,
1993.
(If nominee is minor)
Name
and
Relationship
Date of
Name and Address of person who
Address
with
Birth
may receive the said pension during
of
the
Pensioner
nominee’s minority
nominee
1
2
3
4
------------------------------------------------------------------------------------------------
Name
and
Relationship
Date of
Name and address
Contingency
Address
with
Birth if
of person who may
on happen-
of
other
Pensioner the
other
receive the pension
ing of which
Nominee
in
nominee is minor during the
other
nomination
Case
the nominee
nominee’s
minority
shall become
Under
column (1) above
invalid.
Pre-deceases
the
Pensioner.
5
6
7
8
9
----------------------------------------------------------------------------------------------------------
Place
----------------------
Signature (or thumb)
Date
---------------------
impression if illiterate
Witness:
Signature
and Name of Pensioner
Name
& Address
Address
Signature
of pension Disbursing Authority/Head of Office.
Acknowledgement
to be sent by the pension Disbursing Authority/Head of Office.
Certified
that application/nomination has been received from (Name of Pensioner) whose
address is.
Place
----------------------
Signature of Pension Disbursing Authority
Date
---------------------
Bank/Treasury/PostOffice/Accounts Officer
/
Head of Office.
Full
address:
(FORM-B){See
rule 5(5)}
To
The
Pension Disbursing Authority
(Name
of Bank/Treasury/Post Office/Accounts officer etc.)
(Place)
---------------------------------------
I,
--------------------------------------------- hereby make the following
(Name
of the pensioner in capital letters)
Alternative
nomination in cancellation of the previous nomination made on ----------- under
rule 5 of the payment of Arrears of Pension (Nomination) Rules, 1983.
If
nominee is minor
Name
and
Relationship
Date of
Name and Address of person who
Address
with
Birth
may receive the said pension during
Of
the
Pensioner
nominee’s minority
nominee
1
2
3
4
-------------------------------------------------------------------------------------------------------
Name
and
Relationship
Date of
Name and address
Contingency
Address
with
Birth if
of person who may
on happen-
Of
other
Pensioner
the other receive the pension
ing of which
Nominee
in
nominee
during the other
nomination
Case
the nominee
is minor
nominee’s minority
shall become
Under
column (1) above
invalid.
Pre-deceases
the
Pensioner.
5
6
7
8
9
--------------------------------------------------------------------------------------------------------
Place
----------------------
Signature (or thumb)
Date
---------------------
impression if illiterate
Witness:
Signature
and Name of Pensioner
Name
& Address
Address
Signature
of Pension Disbursing Authority
Date
Stamp -------------------------------
Certified
that application/nomination (Form- B) has been received from
-----------------------------(Name of Pensioner) whose address
is--------------------
Form
A has been cancelled and returned to him.
Place
----------------------
Signature of Pension Disbursing Authority
Date
---------------------
Bank/Treasury/Post Office with full address: