FORM-5 ANNEXURE

 

Particulars to be obtained by the Head Office from the retiring Government Servant before right                     months of the date of his retirement.

1.        Name of the Government Servant……………………………………………………………………………………………

2.        Date Of Birth/Retirement…………………………………………………………………………………………………….

3.        Two specimen signatures duly attested

(furnished in a separate sheet)………………………………………………………………………………………………..

4.        *Three copies of the passport size ** Joint photographs of the

Govt. Servant with his/her wife/husband…………………………………………………………………………………….

5.        Two slips showing the particulars of height and personal

Identification marks duly attested……………………………………………………………………………………………

6.       Present Address………………………………………………………………………………………………………………

 ……………………………………………………………………………………………………………………………….

7.        @ Address after retirement. …………………………………………………………………………………………………

……………………………………………………………………………………………………………………………….

8.        Name of the Treasury/public sector Bank Branch

Through which the Government wants to draw his pension ………………………………………………………………..

9.        @@ Details of the family in form 3

 

Place:                                                                                            Signature ……………………………………………………………           

                                                                                                      Designation………………………………………………………….

                                                                                                      Ministry/Deptt./Office………………………………………………

 

                Two slips each bearing the left hand thumb and finger impressions duly attested, may be furnished by a person who is not literate, enough to sign his name. If such a Govt. Servant on account of physical disability is unable to give left hand thumb and finger impressions, he may give thumb the and finger impressions of the right hand, where a Government Servant has list both the hands, he may give his too impressions. Impressions should be duly attested.

                *Only two of passport size photographs of self need be furnish.

(1)                 If the Government Servant is governed by rules 55 of the CCS (Pension) Rules, 1972 and is unmarried or a widower or widow;

(2)                 If the Government Servant is governed by rules 55 of the CCS (Pension) Rules 1972.

** Where it is not possible for a Govt. Servant to submit a photograph with his wife/her husband he/she may submit separate photographs. The photographs shall be attested by the head of Office.

@ Any subsequent change of address should be notified to the head of office/Audit Office.

@@Applicable only where rule 54 of the CCS (Pension) Rules applies to the Govt. Servant.