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Pension Forms

November 26, 2011

SOUTH WESTERN RAILWAY

PAYMENT OF PF/GRATUITY/CGEGIS/ETC.

(Payee’s letter of Authority for payment by Cheque/Bank Draft)

 

To,                                                                                           Date:-

The Financial Advisor & Chief Accounts Officer,

South Western Railway,

HUBLI.

Dear Sir,

I request that my Provident Fund, Special contribution to Provident Fund or/ Gratuity money or other settlement amount may be remitted to me by Cheque/bank draft on: A/C No: – ,  ………………………Name of Bank  , BRANCH          

at the following address.

…………………………………………………………………………………………………………………………………………………

           I agree that the remittance made in the aforesaid manner shall be at my sole risk and shall be a complete discharge of government from all liability on the money being remitted by money order or in the cheque or bank draft being forwarded by registered post, as the case may be. I enclose herewith a receipt for the amount.

Yours faithfully,

 (Signature/Left Thumb impression)

Date:       /      /2011

Station: HUBLI.

Full name & Address of the payee: –

…………………………………. ………………………

……………………………………………………….

RECEIPT

Received from  FA&CAO/UBL the sum of Rs.____________ (Rupees ___________ _______________________________________) in full and final satisfaction of my claim to the Provident fund amount/Special Contribution to Provident Fund/ Gratuity/Settlement dues etc.

Revenue stamp Rs.1/-

Full Address: …………………………………………………

…………………………………………………………………..

 Forwarded to: – FA&CAO/SWR/UBL for inf. & n.a.


For Chief Personnel Officer

South Western Railway

Application for joining the Railway Employees’ Liberalized Health Scheme – 97 :

Contributory Health Scheme: RELHS.

1. Name of the retired employee                       : .

(in BLOCK LETTERS) as registered

in Railway records.

2.  Designation/Department/Station                  : .

3.  Date of Appointment                                    : .

4.  Date of Retirement                                        : .

5.   Last pay drawn                                             :

Names of persons for whom Medical facilities are required :

Sl.No.                   Name/s                    Relationship                                      Date of birth.

.

.

.

.

7.   Marks of identification of the employee       :.

8.   Permanent Address                                       :  .

.

9.   Whether employed any where?                    : .

  1. Whether Medical Identity Card which was

taken while in service surrendered to the

Supervisor where you were last working      : .

Place:    HUBLI

Date:.                                                                                                    Sign. of the retired employee

Encl:      (1) Xerox copy of Service Certificate attested by a Gazetted Officer

(2) Joint  Photos (self & wife) and separate photos of eligible children (two photos)

(3) Declaration stating that he/she has not joined  the old scheme.

 

SOUTH WESTERN RAILWAY

ANNEXURE-XIII

CONSENT   FOR  ISSUING   MEDICAL  IDENTTY  CARD

I opt for the Re-opening  Retired Employees   liberalized  Health Scheme -97 (RELHS –97)

I have not deposited the contribution for joining the scheme so far I hereby give my consent for

deduction from my  VI  PC  basic pay

1. Retired on the date of Re-Opening.

My basic revised pension to double Rs

2. Family pensioners-

My revised family pension to double Rs-………….

3. SRPF- Optees

My  Ex-gratia monthly  payment admissible Rs—————-

Signature –

Name-

Designation –

Office/ Station-

Date of retirement-

                                                                         ANNEXURE ‘C’

 

BILL NO.                           DATE:-

 

Received a sum of Rs. _________ (Rupees _______________________________only )      being the total settlement of  Rs. ___________________________from the Insurance Fund and/

of Rs. __________ from the Savings Fund account.

Name:

Designation:                                                                                                      Group A/B/C/D under the

Central Government Employees’ Group Insurance Scheme, 1980.

               Signature of the Recipient (s):

                                                                        Name in Block letters:  

                                                                                                                 

For use in the Bill Preparing Office.

 

Relevant Bio-data of the Member:

  1. Type of Group of the Member  :

Lowest group vide D/C/B/A on initially joining the Scheme in January.

Group

From:  To

Amount

Rs.

D

C

B

A

TOTAL :-

Countersigned for payment of Rs. _________ (Rupees ___________________________________________ ) to claimant(s)

Crossed cheque/Demand Draft to be issued in favour of Claimant(s).

Signature:

Date      :

Designation of Bill

Preparing Officer:

FOR USE IN ACCOUNTS OFFICE

 

Passed for payment of Rs. __________

( Rupees _______________________________________________________________).

 

 Accounts Officer:

Annexure-X(to FA&CAO’s letter No-A/PN/HQ/PN/24, DT-04.03.2011)

UNDERTAKING &OPTION FORM

To be submitted by pensioner to his / her Pension disbursing authority

 

I, …………………………………………………………………………….(Name & details)  hereby declare that, an employee of /family pensioner whose(specify relation of family pensioner with deceased Railway employee) SELF ,was an employee of office of ……………………………………………… declare that I am residing at  …………………………………………………………..  which is beyond 2.5 km from the nearest Railway hospital(CH/UBL)/health unit /lock-up dispensary( as contained in Annexure-III), Railway Board letter PC-V/98/1/7/1/1, dated: – 21.04.1999. Accordingly, I hereby opt: –

(i) For OPD medical facility from Railway Hospital / Health Unit /Lock-up dispensaries

                                                                         (OR)

(ii)To claim Fixed Medical Allowance of Rs.100/300 per month.

(Strike out which is not applicable)

Necessary endorsement may please be made in my PPO in this regard.                                                                                                                              

                                                                        Signature

 ………………………………………………….

 

(Counter sign of Head of office)

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