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

 

 

 

 

 

 

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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

 

 

 

 

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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

 

 

 

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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: