Revised Forms for Disability Pension and Extraordinary Pension

Revised Forms for Disability Pension and Extraordinary Pension – DOPT Notification

[TO BE PUBLISHED IN THE GAZETTE OF INDIA, IN PART II, SECTION 3, SUB SECTION (i)]

Government of India

Ministry of Personnel, Public Grievances and Pensions

(Department of Pension and Pensioners Welfare)

New Delhi, the 02.06.2015

NOTIFICATION

G.S.R…… – In exercise of the powers conferred by the proviso to article 309 read with clause (5) of article 148 of the Constitution and after consultation with the Comptroller and Auditor General in relation to persons serving in the Indian Audit and Accounts Department, the President hereby makes the following rules further to amend the Central Civil Services (Extraordinary Pension) Rules, 1939, namely:-

1. (1) These rules may be called the Central Civil Services (Extraordinary Pension) Amendment Rules, 2015.

(2) They shall come into force on the date of their publication in the Official Gazette.

2. In the Central Civil Services (Extraordinary Pension) Rule, 1939, in Schedule IV, for Form A and Form B, the following Forms shall respectively be substituted, namely:-

“FORM A

[See rule 13 (4) (ii)]

FORM OF APPLICATION FOR DISABILITY PENSION

Part I

(To be filled by the applicant)

1.	Details of the Applicant:	Space for Photograph
	(i) Name
	(ii) Designation/Rank
	(iii) IRLA/Personal/ Force/ Regiment No.
	(iv) Aadhaar Number ( if available)
	(v) Marks of Identification
2.	Name of Father OR Mother OR Both
	a) Name of Father
	b) Name of Mother
3.	Date of birth of applicant
4.	(i) Correspondence address with PIN code
	(ii) Permanent address with PIN code
5.	Post held at the time of injury/disease
6.	Bank name,
	Branch address,
	Account No. to which pension is to be credited (joint account, either or survivor, with spouse) BSR Code, IFSC Code
7.	Enclosures: (i) Self-attested copies of certificate of Medical Board, (ii) Form 3 of Central Civil Services (Pension) Rules, 1972 iii) Nomination Forms (except commutation of pension), (iv) Undertaking in Form 26 of Central Civil Services (Pension) Rules, 1972 (if applicable), (v) Undertaking for refunding any excess payment, (vi) Specimen signature/thumb impression (in case of illiterate applicant) (vii) Three joint photographs with spouse or separate photographs of the applicant and spouse where it is not possible to submit a joint photograph, {Note: Thumb impression ( in the case of illiterate applicant) is to be attested by a Gazetted Officer and photo ars are to be attested b Head of Office}

(Note: In case the Head of Office is satisfied that it is not possible for the applicant to open a joint account for reasons beyond his/her control, this requirement may be relaxed.

Place: Date:	———————- Signature of Applicant
	Contact Number: _______________________ e-mail ID: __________________

Date of receipt of Form:	——————————— Signature of Head of Office with seal

Part II

(To be filled by the Head of Office and forwarded to Accounts Officer)

1.	(i)	Present/last post held
	(ii)	Post held at the time of injury/disease
	(iii)	Head quarters/unit with address
	(iv)	Service to which belongs
2.	(i)	Date of entry into service
	(ii)	Date of discharge/boarding out from service
3.	Net qualifying service
		(a) Actual
		(b) Notional for categories ‘D’ and ‘E’
5.	(i)	Basic pay on the date of injury/disease
	(ii)	Basic pay on the date of medical examination (include non-practising allowance in the basic pay)
6.	Percentage of disability sustained due to injury/disease (as certified by the medical authorities) and circumstances which resulted in that disability
7.	(i)	Date of injury/disease (as certified by the medical authorities
	(ii)	Date of medical examination
8.	Amount of retiremet gratuity/death gratuity
9.	(a)	Proposed disability pension
	(b)	Date from which pension is to commence
10.	Rate of extraordinary family pension if death occurs within 7 years from the date of injury or date of medical report on disease and is on account of the same injury or disease for which he was boarded out.
11.	Rate of family pension in case of death other than as in item 10
		(i) Enhanced rate
		(ii) Ordinary rate
		(iii) Period for which family pension will be payable
			(a) at enhanced rate
			(b) ordinary rate

———————————————-

Signature of Head of Office with seal

Accounts Officer

FORM B

[See rule 13 (4) (ii)]

FORM OF APPLICATION FOR FAMILY PENSION

Application for extraordinary family pension in respect of late Shri/Smt. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ killed or died of injury(ies)/disease(s) claimed as attributable to Government Service.

I. Information regarding the deceased

1.	Full name and address
2.	Name of Father OR Mother Or Both
3.	Date of death

II. Information regarding the claimant

4.	Name and address, (showing Village, Post Office, District, State, PIN code)
5.	Date of birth
6.	Aadhaar Number (if any)
7.	Monthly income from all sources
8.	Relationship with the deceased
9.	Bank Name Branch Address Account No. BRS Code/IFSC Code

III. Details of surviving members of family of the deceased

Relation	Name	Date of birth (Christian Era)	Disability, if any	Marital status
Widow/Widower
Sons
Daughters
Father
Mother
Brother
Sister

IV. In case the claimant is minor or suffering from disorder or disability of mind, including mental retardation, details of guardian/nominee, wherever applicable-

Name	Date of birth	Relationship with the minor/ mentally disabled claimant	Relationship with the deceased Government servant	Postal address

Enclosures:

(Copies of):

1. Report of medical examination of the deceased employee

2. Guardianship certificate, if applicable

3. Disability certificate of the claimant, if any

4. Income certificate

Specimen signature/thumb impression and two photographs of the applicant, attested by a Gazetted Officer are enclosed.

Place:

Date:

(Signature of claimant) _______________________

Phone No: ______________

Permanent Account Number for Income Tax (PAN)_______________

Aadhar No., if available _______________

NOTE: If the deceased has left no son, widow, daughter, father or mother, brother or sister surviving him, the word “None” should be entered opposite to such relative.

Place:

Date:

(Signature and Seal of Head of Office)

Download DOPT Notification for revision of forms for Disability Pension and Extraordinary Pension dated 02.06.2015