Integrated Financial and Human Resources Management System (IFHRMS) Printed Copy

ANNEXURE -- I

APPLICATION FOR FINAL SETTLEMENT OF CONTRIBUTORY PENSION SCHEME ACCOUNT

[Vide G.O.Ms.No.59, Finance (PGC) Department, Dated 22nd February, 2016]

(Please ensure that all the relevant Particulars are given with certificates where necessary to avoid delay in settlement of
claim)

(To be sent in Triplicate)

1. Name of the Subscriber [in BLOCK LETTERS] : JACOB JESURAJ J

2. IFHRMS Employee ID 43020064434
3. Designation : Bachelor Of Teaching Assistant| |40850
4. Contributory Pension Scheme Account Number : 732863
with Departmental Suffix
5. Date of Birth : 08-MAR-1963
6. Religion : Christian
7. Date of Entry into Service : 15-SEP-2010
8. Office in which Attached : ASSISTANT ELEMENTARY EDUCATIONAL OFFICE,
ANTHIYUR
9. Treasury / Sub-Treasury where bills of the Office : ST ANTHIYUR
are presented
10. Residential Address after Retirement : 1/3,C/NORTH STREET, ACHANKOTTAM(PO),V.K.PUTHUR
11. Event necessitating closure of account : Death While in Service
(a) Retirement on Superannuation : -
(attach a copy of the order)
(b) Voluntary Retirement : -
(copy of orders to be enclosed)
(c) Resignation : -
(attach a copy of the orders of acceptance
of resignation)
(d) Dismissal / Removal / Compulsory Retirement / : -
Invalidation Date
(i) Have you preferred an appeal? : --
(ii) If yes, date of its disposal / withdrawal : --
(iii) If no, date of expiry of the appeal time : --
(iv) If no appeal has been preferred give an : I hereby undertake that no appeal shall be preferred
undertaking that no appeal will be preferred in by me against my dismissal / removal / compulsory
future. retirement / invalidation
(e) Date of Death : 07-MAY-2022
(i) Has the subscriber filed any nomination : Yes
(If yes, enclose nomination in original)
(ii) If No or if the nomination has been rendered null : -
and void who are surviving family members on
the date of death of the subscriber (Enclose a
Legal Heirship Certificate)

Sl. Names of the Claimant Relationship with the Date of Birth Age Marital
No Subscriber Status

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 Integrated Financial and Human Resources Management System (IFHRMS) Printed Copy
1 PANIMARY J Spouse 15-APR-1966 58 -
2 MARIA VASANTH J Son 10-MAY-1990 34 -
3 MARIA ANANTH J Son 02-APR-1993 31 -
4 PRAVIN Son 29-MAR-1994 30 -
5 BRUNDHA Daughter 20-JAN-2001 23 -
6 JEEVITHA J Daughter 17-JUN-2003 21 -

(iii) If any of the nominee died after the subscriber : --

but before receiving of the payment. Please
furnish details thereof
(iv) If there is no nomination and if the Subscriber : --
has left no family to whom should the money
be paid? (Enclose Letters of probate or
succession certificate)
(f) Transfer of Balance : --
(i) Date of absorption on permanent basis : --
Organization to which transferred / joined on
permanent basis.
Is absorption on Permanent basis?
(ii) Is the absorption with the approval of State : --
Government? If so, details of orders may be
furnished?
(iii) Accounts Officer to whom the balance is to be : --
transferred
12. Name and Address of Offices served during : --
the last 3 years

Sl. Name of the Office Address Period of Designation

No. Service
1 ASSISTANT ELEMENTARY EDUCATIONAL OFFICE, ERODE 9 Years 7 Months Bachelor Of
ANTHIYUR 16 Days Teaching Assistant|
|40850
2 ASSISTANT ELEMENTARY EDUCATIONAL OFFICE, ERODE 0 Years 2 Months Bachelor Of
ANTHIYUR 0 Days Teaching Assistant|
|40850
3 ASSISTANT ELEMENTARY EDUCATIONAL OFFICE, ERODE 1 Years 10 Bachelor Of
ANTHIYUR Months 7 Days Teaching Assistant|
|40850

13. Particulars of Last CPS Deductions:

Sl. Pay for CPS CPS Gross Net Date of Place of Head of Voucher
No. Month Subscription Arrears Amount Amount Encashment Payment Account Number
of Bill of Bill
1 ST
ANTHIYU
R

14. Period during which subscriber was on EOL / : --

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 Integrated Financial and Human Resources Management System (IFHRMS) Printed Copy
Suspension or any other leave period during
which no subscription was recovered.
15. Whether a Self-Drawing Officer --
[Drawing a Pay in the scale of Pay of ] :
If Yes
(a) Treasury / PAO at which CPS payment is : --
desired
(b) Enclose the following : --
(i) Personal Marks of Identification : A BLACK MOLE RIGHT SIDE BELOW OF THE LIP

A BLACK MOLE LEFT SIDE THROAT PIT

(ii) Specimen Signature or left/right hand thumb

and fingers impression : --

16. I hereby undertake that I will not claim any further due for pension / family pension settlement / benefits in
future Under Contributory Pension Scheme.

17. I hereby undertake to refund any excess payment arising out of clerical errors in the settlement of C.P.S. claims.

Station: Signature of the Claimant.

Date:
(With Name in BLOCK LETTERS)

FOR THE USE BY HEAD OF OFFICE/ DEPARTMENT

Certified that all the particulars furnished above have been fully verified with reference to office records and are found
correct.

Station: Signature of Head of Office /

Head of Department
Date:
(With Name in BLOCK LETTERS)

Government of Tamil NaduPage 1 of 2Generated in IFHRMS on: 22-MAR-2024 12:44

 Integrated Financial and Human Resources Management System (IFHRMS) Printed Copy

Government of Tamil NaduPage 1 of 2Generated in IFHRMS on: 22-MAR-2024 12:44