Single Comprehensive Form for Pension Preparation of West Bengal Govt Employees Only

DATA INPUT SHEET

Single Comprehensive Form for Pension Preparation of West Bengal Govt Employees Only. Prepared by Pranab Banerjee, Jiaganj, Kalisthanpara, Murshidabad, West Bengal. Email :pranab.banerjee83@gmail.com OR Cell No.9474316768, 8906279547. This Software Prepared at a time the Single Comprehensive Form + Pension Calculation + Family Pension Calculation + Gratuity Calculation. Just Put this DATA INPUT SHEET PROPERLY.
1 2 3 4 5 6 Name of the Govt Employee( Block Letters) Designation of the Employee Father's/Husband's Name(Block Letters) U.D.C. LATE- ANANTA MUKHERJEE KALPANA MUKHERJEE PANCHANAN MUKHERJEE

Name of the recipient of Family Pension(In Block Letters) Relationship with the Govt Employee Present Address of Employee Village Kalisthanpara :P.O. Jiaganj Wife

Dist

Murshidabad

Pin Code

Permanent Address of the Employee:Village Kalisthanpara P.O. Jiaganj Dist Murshidabad Pin Code

Present Address of the Family Pensioner's(Wife/Husband/Daughter/Son):Village Kalisthanpara P.O. Jiaganj Dist Murshidabad Pin Code

Permanent Address of the Family Pensioner's (Wife/Husband/Daughter/Son):Village Kalisthanpara P.O. Jiaganj Dist Indian, Hindu Murshidabad Pin Code

10 11

Nationality /Religion of the Govt Employee

Name & Address of the Office which the employee Last Serve or retire/death :Name of Department P.O. Telephoneno Land & Land Reforms Department Lalbagh 3483265987 Land & Land Reforms Department 6254 ADMN/WB/558899 DD MM 10 DD 2 8 MM 4 Dist. Murshidabad Pin Code

12 13 14 15 16

Name of the Department of the Retire/death employee Employer/PSA'S Number G.P.F Account Number of the Employee Date of Birth of the Employee Date of Apointment of the Employee

YY 1949 YY 1969 Put only the figure in DD/MM/YY

Put only the figure in DD/MM/YY DD 17 19 Date of Retirement of the Employee Last Pay Band No( Scale No.) Last Grade Pay Last D.A. Drawn 20 3900 7382 Lalbagh Treasury-I 31 3 Last Pay Band Pay Last Basic Pay with Grade Pay MM 8 YY 2009 17190 21090

Name of the Treasury/PAO with unit no. i.e. I or II (where his Residence attached with this T.O.) Name of the Treasury/PAO (with Unit No. i.e. I or I I ) with which Treasury attached with Employees Office where from he Retired) Name of the Bank Branch (Where the Pensioner drawn his Pension) United Bank of India, Jiaganj Branch Bank of Branch BSR Code No. 00555

21

Lalbagh Treasury -I

21

22

Savings Bank Account No of the Employee (Which Account of Bank is related to Pension)

0055226699 [Enclosed Annexure A in duplicate] Identification Marks of the employee One Cut Mark on the left feet

23

Height of the Employee 5'-3"

24

Details of the Family Members of the Employee:Name Date of birth Age Relationship Marital Status Date of Marriage

1 2 3 4 25 26 Head of Account to which pension is chargable Date of applying for Pension/Family Pension 1/7/2008 2271 - Retirement Benefits

(The Date will be the just previous One Year from Retirement Date) 28 29 30 31 32 Whether Commuted Pension wanted Yes 98.328 0 0 0

Commuted Values for Pension of Re 1 per annum(CVP) Out standing Amount of House Building Advance if any Out standing Amount of Marriage & Illness Advance if any Out standing Amount of Cycle/Scooter/Car/Computer Advance if any

33 34

Out standing Amount of Festival Advance if any Any Overdrawal of Pay/Allowances if any 0

es Only

nly. Prepared :ared at a time + Gratuity

742123

742123

742123

742123

774455

he figure in M/YY

he figure in M/YY

te of Marriage

SINGLE COMPREHENSIVE FORM (As per Memo. No. 359-F(Pen) dt. 16.04.2009) PLEASE FILL IN ALL THE ITEMS PROPERLY AND CAREFULLY. IN CASE A PARTICULAR ITEM IS NOT APPLICABLE, PLEASE STATE SO. BUT DO NOT LEAVE THE ITEM BLANK. THIS FORM NOT COMPLETED IN ALL RESPECTS WILL NOT BE ACCEPTED AND A FRESH SINGLE COMPREHENSIVE FORM MAY BE CALLED FOR. 1 2 3 4 a Name of the Govt. employee (IN BLOCK LETTERS) Designation of the Govt. employee Fathers/Husbands Name of the Govt. employee Name of the recipient of family pension (IN BLOCK LETTERS ) b Relationship with Govt. employee 5 a Address of the Govt. employee : Present Vill District b Permanent Vill District 6 a Kalisthanpara Murshidabad Kalisthanpara Murshidabad P.O. Pin Code P.O. Pin Code Jiaganj 742123 Jiaganj 742123 Wife KALPANA MUKHERJEE

PANCHANAN MUKHERJEE U.D.C. LATE- ANANTA MUKHERJEE

Address of the family pensioner (in case of death while in service/after retirement) Present Vill District b Permanent Vill District Kalisthanpara Murshidabad Kalisthanpara Murshidabad P.O. Pin Code P.O. Pin Code Jiaganj 742123 Jiaganj 742123

7 8

Nationality and Religion Name of the establishment last served/serving with full Address and Telephone No. / FAX No.

Indian, Hindu Land & Land Reforms Department P.O. District Lalbagh Murshidabad Telph.No Pin Code 3483265987 774455

b Name of the Department 9 10 Employer / PSAs code No. Status of the Govt. employee (Temporary/Permanent) b b. Whether work-charged employee c Whether appointment is made on ad-hoc basis and if so, whether regularised subsequently (enclose copy of Govt. order) Whether a member of General Provident Fund (GPF), if so quote GPF Account No If anytime whether he was a member of Contributory Provident Fund (CPF), If so, quote CPF Account No. If he was a member of Contributory Provident Fund (CPF), whether the employers share of CPF along with interest and additional interest accrued thereon has been credited to the Govt. Account (with full particulars mentioning the period for which refund made)

Land & Land Reforms Department 6254 Permanent Nil No ADMN/WB/558899 NO

11 12

13

No

14 15

Pension Rules and relevant Govt. order applicable in this case Class of Pension applicable (i.e. Superannuation /Family / Retiring / Invalid Prorata/ Compensation etc)

Rule 57 of DCRB Rules 1971 Superannuation

16

Govt. / Non-Govt. organisation under which NIL

service has been rendered (in order of employment & showing the periods served under each govt.) 17 a Date of Birth of the Govt. employee ( by Christian era) b Date of appointment c Date of Retirement d Period of gross service e f Period of war/military service, if any Details of period(s) of Service on deputation 40

Day 10 2 31 Years 4

Month 8 4 8 Months NIL 29

Year 1949 1969 2009

Orgination NIL

From NIL

To NIL

Remarks NIL

terms to Govt.unertakings/Autonomus bodies/ Local bodies etc. g Amount and nature of Pension/Gratuity Received for Military service h Whether opted for Family Pension on account of Military Service 18 Non-qualifying service : a EOL without medical certificate

Contribution Received NIL

NIL NO

NIL NIL NIL Years 40 Month 4 Day

b Period of suspension not to be counted towards pension etc. c 19 20 Other non qualifying service, if any Net qualifying service (Gross service minus non-qualifying service Weightage of Service admissible, if any.

29

i.e.

33

(Employee retired on or after 25/02/2009, the benefit of weightage under rule 27 of WBS (DCRB)Rules, 1971 is not applicable) 21 Total service qualifying for pensionary benefits (19+20). a Last pay drawn with scale of pay b Proposed Superannuation Pension/Retiring Pension / Invalid Pension/Pro-rata pension/Compensation Pension. c ProposedRetiring Gratuity/Death Gratuity d Proposed family pension, if applicable 22 Date on which the Govt. employee/family pensioner applied for pension 23 Date from which pension/family pension is to commence

Does not arise

33 Years
Pay Band No

Grade Pay

3 3900

Pay Band Pay Basic Pay

17190 17190

Rs. 10545

Rs. 469,788
Rs 10545 Up to 30 7

Thereafter

Rs. 6327 1/7/2008

1/9/2009

Whether commutation of pension wanted? be commuted

Yes

b If so, amount/portion of pension to c Date on which application for commutation has been received by the pension sanctioning authority d Proposed amount of Reduced Pension ( in case of commutation applied and sanctioned) e Proposed amount of CVP (enclose applicat ion for commutation in prescribed form duly accepted by( PSA) 24 Place of payment of Pension /Family Pension (State clearly the name of Treasury with Unit No. i.e. I or II if payment is desired in West Bengal.) 25 Name of the Treasury / PAO (with Unit No. i.e. I or II) with which Pension Sanctioning Authority attached 26 a the jurisdiction of Kolkata Corporation area, If so, Name of the Bank & Branch Name of the Bank of Branch B.S.R. CODE NO 00555 Lalbagh Treasury -I Lalbagh Treasury-I Rs. 414,748 Rs. 4218 1/9/2009

Whether payment of pension /family pension is desired through a Public Sector Bank within

United Bank of India, Jiaganj Branch (with B.S.R. Code No. of the Paying Branch as as well as Link Branch) 0055226699 b S/B A/c. No. (in single name /joint name) (Enclose Annexure A in duplicate) 27 Descriptive Roll of the pensioner/family pensioner(enclose descriptive roll in 3 separate sheets with the following information) : (i) Height (ii) Identification marks 5'-3" One Cut Mark on the left feet

(ii) Left Thumb and finger impression Thum Fore finger Middle finger Ring finger little finger THUMB FORE FINGER MIDDLE FINGER RING FINGER LITTLE FINGER

(Persons who are literate enough to sign their names in English, Hindi or the Official Regional Language, are exempted from recording their left thumb and finger impressions) 28 Statement of family members (including unmarried / widowed /divorced daughter beyond 25 years & physically crippled and mentally retarded son/daughter beyond 25 years) Relationship with Sl No Name(s) Date of birth Matrital Status Age category 1 2 3 4 -

29 Whether nomination made for LTA/ Family Pension b If so, state the name of the nominee (enclose the nomination paper in duplicate) c If not, state the name(s) of the legal heir(s), his/her/their age, share payable and relationship with the deceased pensioner/family pensioner where LTA of pensionary benefits are payable. 30 a (For Death cases only) Whether nomination made for death-gratuity (Yes/No) b If so, state the name (s) of the nominee (s), his/her/their relationship with the Govt. employee and share payable with pension papers ) c

Yes

KALPANA MUKHERJEE Does not Arise

No

Does not Arise

(Enclose two copies of the duly accepted nomination form - one in Service Book and other State below the details of surviving family members [Defined in Rule 7(1) of the W.B.S.(DCRB) Rules, 1971 Statement of the Family Members Sl. No 1 2 3 4 Name(s) Date of Birth Age Relationship with category Matrital Status Date of marriage in case of married daughters included, if any 1/0/1900 1/0/1900 1/0/1900 1/0/1900

31 a

N.B. : Daughters married before death of Govt. employee do not fall in the definition of Family for the purpose of Death Gratuity. Outstanding dues of the Govt. employee House Building Advance 0 0 0 0 0

b Marriage & Illness Advance c Cycle /Scooter/Car Advance/Computer Advance

d Festival Advance e Overdrawal of pay/allowances , if any, with the Head of Account under which it is to be credited f Any other outstanding dues with H ead of Account under which it is to be credited 32 a Provisional Pension/Family Pension paid, (Please state the rate and the period for which if any paid) b Provisional gratuity/death gratuity paid, if any c 33 Interim relief paid, if any

Nil

Nil Nil Nil 2271 - Retirement Benefits No No

Head of Account to which pension/gratuity is chargeable 34 a Whether the Govt. employee is re-employed afterretirement b If so, details of re-employment and fixation of

re-employed pay may be stated with necessary order of competent authority.

No

35 a

Whether the family pensioner is employed (widow/widower) .

No

b Whether the Family Pensioner is in receipt of any other Pension/Family Pension. If so, details thereof. 36 Please state the name of legal guardian who will draw the share of LTA pension/family Pension /gratuity/death gratuity in favour of minors. 37 Whether any vigilance case/court case/departmental or criminal proceedings is pending against the Govt. employee. If so, give details with supporting documents. 38 Any other Remarks Nil Does not arise No

No

39 (A) The undersigned having satisfied himself that the above particulars are true and that the service of the Govt. employee has been thoroughly satisfactory hereby orders the grant of the full pension/family pension, death-cum -retirement gratuity which may be accepted by the Accountant General & as admissible under the rules. Or (B) The undersigned having satisfied himself that the service of Shri/Shrimati/Kumari-----------KALPANA MUKHERJEE has not been throughly satisfactory

here by orders that the full pension/family pension/death-cum-retirement gratuity, which may be accepted by the Accountant General & as admissible under the rules shall be reduced by the specified amount or percentage indicted below:Amount or percentage of reduction pension/family pension-------------------------------------Amount or percentage of reduction in gratuity-------------------------------------------. The grant of pension/family pension, death-cum-retirement gratuity -------------------------------------------------------. (Inapplicable portion should be scored out) This order is subject to the condition that if the amount of pension and/or gratuity as authorised be afterwards found to be in excess of amounts to which the pensioner is entitled under the rules, he/she shall remain liable to refund such excess.

Dated : Signature Full Name Designation of the Pension Sanctioning Authority

ULAR

THIS FORM

GLE

JEE

RJEE

EE

Jiaganj 742123 Jiaganj 742123

Jiaganj 742123 Jiaganj 742123

3483265987 774455

artment

1971

Year 1949 1969 2009 Days Contribution Received NIL

Years

17190 17190

2016

B.S.R. CODE NO 00555

t feet

Date of Marriage 1/0/1900 1/0/1900 1/0/1900 1/0/1900

EE

RB) Rules, 1971

marriage in case of rried daughters ncluded, if any 1/0/1900 1/0/1900 1/0/1900 1/0/1900

efits

e specified

Form A
Nomination for Death Gratuity
(When the Government Servant has a family and wishes to nominate on member thereof) I hereby nominate the person mentioned below who is a member of my family, and fonfer on him the right to receive any gratuity that may be sanctioned by Government in the emvent of my death while in service and the right to receive on my death any gratuity which having become admisible to me on retirement may remain unpaid at my death Name and address and relationship of the person or persons if any, to whom the Contigencies on the right conferred on the nominee Amount happening of which shall pass in the event of the or share the nomination shall nominee predeceasing the of be come invalid officer or the nominee dying gratuity after the death of the officer but before receiving payment of the gratuity Vill 0 0 Divorce or Insanity P.O. Dist Pin Code Kalisthanpara Jiaganj Murshidabad 742123 100%

Relations Name and Address of Nominee hip with Officer

Age

KALPANA MUKHERJEE Vill P.0. Dist Kalisthanpara Jiaganj Murshidabad

This nomination supersedes the nomination made by me earlier. Nilwhich stands cancelled. Dated this. Day of 20..at office of the .. Witness to signature:1. 2

Signature of the Employee Note:- The last column should be filled in to cover the whole amount of Gratuity ( to be filled in by the Head of office in the case of Non-Gazetted Officer) Nominated By : Designation : Department Signature of the Head of Officer with Seal

Form C
(to be submitted in duplicate)

PART-I
[Rule 14(1)(a)]

Form of application for Commutation of Pension whthout Medical Examination

I furnish below the relevant particulars and request that may be permitted to commute a portion of my Pension as indicated below:1 Name (In Block Letters) 2 Date of Birth 3 Date of superannuation on attaining the age of 60 years) 4 Designation of the post held at the time of Superannuation and the name of the Department/Office 5 Amount of pension sactioned and whether it is provisional or final 6 Class of pension as defined in the West Bengal Service(Death-cum-Retirement Benefit) Rules, 1971 7 Name of the Treasury or Bank and Account Number from which pension is being drawn 8 Name of the Treasury or Bank through which the commuted value is desired to be paid,if payment is not desired through the Accounts Officer who authorised the pension 9 Designation of the Accounts Officer and the Nunmber and date of the Pension Payment Order, if issued: 10 Amount( in whole rupees) of pension and protion of pension proposed to be commuted 11 Particulars of any application for commutation of pension made previously and whether appeared before any Medical Authority or not Dated:Signature of the Applicant with Full Address Accepted Nil A.G.West Bengal 40% of my Pension i.e. Rs. 0 Lalbagh Treasury-I Superannuation U.D.C. PANCHANAN MUKHERJEE 1/10/1900 31

Not Yet Sanctioned

Lalbagh Treasury-I