Common Nomination Form for Arrears of Pension and Commutation of Pension – Form A
Form A
(Common Nomination Form for Arrears of Pension and Commutation of Pension)
[See Rule 5 of Payment of Arrears of Pension (Nomination) Rules, 1983 and Rule 7 of Central Civil Services (Commutation of Pension) Rules, 1981]
I, ………………………………………………………………………………., hereby nominate the person/persons mentioned below and confer on him/her/them the right to receive in the event of my death, to the extent specified below, amount on account of the following:
- Arrears of Pension
- Commuted Value of Pension payable under Central Civil Services (Commutation of Pension) Rules, 1981
| Name, date of birth (DOB) and address of the nominee | Relationship with employee/ pensioner | Share to be paid to each | If nominee is minor, name, DOB and address of person who may receive the amount on behalf of minor | Name, DOB and address of alternate nominee in case the nominee under Column (1) predeceases the employee/ pensioner | Relationship with employee/ pensioner | Name, DOB and address of person who may receive the amount if alternate nominee in Col. (5) is a minor | Contingency on happening of which nomination shall become invalid |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
These nominations supersede any nominations made by me earlier.
Place and date:
Signature of Government servant/Pensioner
Telephone No.
Note 1 : Completely strike out the benefit for which nomination is not intended to be made. Separate copies of this nomination Form may be used for nominating different persons for benefits (i) and (ii) above.
Note 2 : The Government servant shall draw lines across the blank space below the last entry to prevent the insertion of any name after he/she has signed. The nominee(s)/alternate nominee(s)’ shares together should cover the whole amount.
(To be filled in by the Head of Office/ authorised Gazetted Officer)
Received the nominations, dated …………., under the following Rules:
- Payment of Arrears of Pension (Nomination) Rules, 1983
- Central Civil Services (Commutation of Pension) Rules, 1981
made by Shri/Smt./Kumari……………………………….
Designation……………………………………
Office……………………………………
(Strike out which nomination is not received)
Entry of receipt of nomination(s) has been made in page …………Volume……….of Service Book. Name, Signature and Designation of Head of Office/authorised Gazetted Officer with seal
Date of receipt…………………………………..
The receiving Officer will fill the above information and return a duly signed copy of the complete Form to the Government servant who should keep it in safe custody so that it may come into the possession of the beneficiaries in the event of his/her death.
The receiving officer shall put his/her dated signature on both pages of this Form.
****
Related: Common Nomination Form for Gratuity, GPF and CGEGIS – Form 1
COMMENTS