FORM OF THE APPLICATION FOR SERVICE PENSION/ FAMILY PENSION/ RETIREMENT GRATUITY/ SERVICE GRATUITY/ COMMUTATION

(To be furnished in duplicate)

G.O.Ms NO.263, Dated : 23-11-1998

Part – “I Information to be furnished by the Government Servant/Applicant”

(The Pension Sanctioning authority shall forward the application duly processed

to the AG(A&E)/LF Authority within a period of 30 days)

a) Name of the Government servant

b) Post held

Name of the Applicant

( in case of death of government servant)

Permanent Address

Address after retirement

Commutation of Pension

a) Whether willing to commute 40% of

monthly pension, subject to AP Civil

Pensions (Commutation) Rules,1944.

b) If the answer is ‘NO’ specify the

fraction less than 40%

YES/NO

6. a) Name of the Pension Disbursing

Authority

b) Name of the paying Bank from

where pension payment is desired

by the pensioner/family pensioner/

gratuitant

Name of the

Bank and Branch

S.B.Account

No.

7. LIST OF FAMILY MEMBERS
(a)	(b)	(c)	(d)	Marital/Employment status of the children of the applicant/deceased Government servant
Sl. No.	Name of the family member	Date of Birth	Relationship with government servant	Married or unmarried Date of Marriage if married	Whether employed or not, Give details of employment






*Instructions* : 1. The Government servant is instructed to fill up the proforma very carefully as the data furnished is vital for sanction of family pension. He/she may note that alternations of the data furnished at a later date is not permissible. 2. The “family” for the purpose mean “wife” or “husband” as the case may be, “sons” and “unmarried daughters” as laid down in Rule 50(12) (for Family Pension) and Rule 46(5)(for gratuity) of AP Revised Pension Rules. 1980. In case of death while service of Government servant, the answer ‘Married’ in case of daughters will be understood that the daughter is already married as on the date of the death of Government servant.

DECLARATION

I undertake to refund the amount of Pension, Gratuity and commutation, it if is found subsequently to be in excess of the amount to which I was entitled under the Rules.

I solemnly affirm that the particulars given by me in Part-I at item 7 are correct and true to the best of my knowledge. If found false in future, I am liable for suitable action as may be taken by the Government.

The particulars given above are correct and true to the best of my knowledge. If found false in future, I am liable for suitable action as may be taken by the Government.

Place :

Date : Signature of the

Government Servant/Applicant

TO BE FILLED IN BY THE HEAD OF THE OFFICE

Application for pension/gratuity etc. in Part I is received on

(Date to be recorded)

Certified that the person/persons mentioned by the Government servant /Applicant in item 7 pf Part I are legally entitled to receive the pension/share in gratuity.

Guardianship Certificate : (to be filled in wherever necessary)

This is to certify that the following minors of the deceased Government Servant Late Sri/Smt _______________________________ is /are under the guardianship of

Sri/Smt __________________________________

Name Date of Birth

Place : Signature of the

Head of the Office

Date :

Office Seal

Part – II(A) Information to be filled up by the Pension Sanctioning Authority
1. Name of the Government Servant and post held
2. Father’s Name /Husband’s Name
3. Name of the Applicant (in case of death of government servant)
4. Date of Birth of Government servant
5. Date of entering into service
6. Date of retirement/death
7. Designation and office from which the Government servant retires/retired/died
8. The rule applicable a) The relevant Rule under the AP Revised Pension Rules, 1980 applicable (tick the rule numbers(s) applicable and strike out the rest) b) Whether ANTICIPATORY PENSION is being sanctioned in terms of Rule - 51. c) Whether PROVISIONAL PENSION is being sanctioned in terms of rule9(4) read with Rule 52. d) Any other rule applicable	Rule 33 Superannuation Pension (Rule 42)
	Rule 34 Retiring Pension (Rule 43/44)
	Rule 35 Pension on absorption under a corporation
	Rule 37 Invalid Pension
	Rule 38 Compensation Pension
	Rule 39 Compulsory Retirement Pension
	Rule 40 Compassionate Allowance
	Rule 43 Retirement on completion of 20 years of qualifying service
	Rule 44 Retiring on completion of 33 years of qualifying service
	Rule 46 Retirement Gratuity
	Rule 50 Family Pension
	YES/NO
	YES/NO
9. Total service (6-5)
10. Periods of non-qualifying service a) E.O.L b) Suspension period c) Dies-non d) Boy service e) Any other service not qualified for pension Total non-qualifying service(a to e)

11. Net qualifying service (9-10)
12. Weightage, if any
13. Total qualifying service for calculation of pension (11+12)
14. Last pay drawn (Rule 31,46(4), 50(12)(c) of APRPRs, 1980) Para 4 of G.O.Ms No.87 Fin. & Plg. (FW-Pen.I) Dept. dt .25.5.98
15.Calculation of service pension/service Gratuity (Rule 45 of APRPRs, 1980)
16. Calculation of Retirement gratuity (Rule 46 APRPRs,1980)
17. Calculation of Family pension a) Service Pension b) Enhanced Family Pension c) Normal Family Pension	As applicable to the case under consideration
	From till death
	From To
	From To
19. Government dues to be recovered in respect a) House building Advance b) Motor car /Cycle Advance c) Marriage Advance d) Advance Leave Salary e) Advance Salary on transfer f) Dues on Account of Government Quarters g) Telephone /Truck Call charges h) Festival Advance i) Education Advance j) Computer Advance k) Other Government Dues Total	Principal	Interest	Total












Note : Information with conditions will not be accepted by Pension Issuing Authority. Amounts for recovery should be specified and should be in whole rupees. Absence of information will be understood as no dues for recovery
20. LPC is enclosed/LPC will be sent after retirement

PART – II(B)

SANCTION OF PENSION

a) Certificate of competency to accord sanction (applicable in case of sanction of pension to non-gazetted officers including Class-IV employees)

i) I am declared by the Head of the Department to be the Head of an office to accord sanction in this case under the powers delegated vide G.O.Ms No.262, Finance & Planning (FW-PSC) Department dated 23-11-98.

ii) I am the next Gazetted Authority in the hierarchy to the Head of the office in this case who is a non-gazetted officer and hence, I am competent to accord sanction under the powers delegated vide G.O.Ms No.262, Finance & Planning (FW-PSC) Department dated 23-11-1998

(Strike off whichever is not applicable)

b) Sanction Order :

Pensionary benefits including commutation found admissible under the rules may be authorized. It is verified from the records in my custody and certify that no disciplinary or judicial proceedings are pending/contemplated against retiring/retired government servant to whom I am the authority for sanction of pension.

i) Service pension :

ii) Retiring gratuity :

iii) Commutation :

iv) Family Pension :

a) Enhanced Family Pension :

b) Normal Family Pension :

Office Seal Signature and Designation of

Pension Sanctioning Authority

Date

Note 1 : This is to be prepared in duplicate by the Pension Sanctioning Authority, one for the record pf Pension Sanctioning Authority and the other one to be sent to Accountant General/Local Fund Audit Officer.

Note 2 : The Pension Sanctioning Authority should satisfy about the correctness of the particulars of family furnished by the Government servant/Applicant in Part-I

Note 3 : If the Pensionary benefits are not to be released Part-II-B(b) shall be struck off.

Note 4 : If there is any likelihood of delay, Anticipatory Pension/Anticipatory Gratuity as per Rule 51 of A.P.Revised Pension Rules 1980 shall be drawn and paid by the Head of Office to the beneficiary without any delay.

Note 5 : Heads of Departments are those listed in Appendix –I mentioned in Article 6 of A.P.Finanial Code Volume-I/Subsidary Rule 32(ii) of FR 9.

DECLARATION

Name Date of Birth

Part – II(A) Information to be filled up by the Pension Sanctioning Authority