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FORM-7 [See rule 57, 58(6), 61(1), 63; 64(2) and (3), 68 (1) and (7)]
FORM FOR ASSESSING PENSION AND GRATUITY (To be sent in duplicate if payment is desired in a different circle of Audit)
PART - I
1. Name of the Government Servant
:
2. Father’s name (and also husband’s Name in
the case of female Government Servant)
:
3. Date of Birth (by Christian Era)
:
4. Religion
:
5. Permanent residential address showing village, town
district and state
:
6. Present or last appointment including name of the
establishment
(i) Substantive
(ii) Officiating, if any
:
7. Date of beginning of service
:
8. Date of ending of service
:
9. (i) Total period of military service for which pension
or gratuity was sanctioned.
(ii) Amount and nature of military pension gratuity
received from the military services.
:
10. Amount of and nature of any pension/gratuity received
for previous civil services.
:
11. Government under which services has been rendered in
order of employment
:
12. Class of pension applicable.
:
13. The date on which action initiated to :
(i) Obtain the ‘No demand certificate from the
department in charge of building as provided
in rule 52*
(ii) Assess the service and emoluments
qualifying for pension as provided in rule 57
and 61*
:
(iii)Assess the government dues other than the
dues relating to allotment of government
accommodation.
14. Details of omissions, imperfections or deficiencies in
the service book which have been ignored.
:
15. Total length of qualifying service (for purpose of adding
towards broken periods, a month is reckoned as thirty
days).
:
From To
16. Period of non-qualifying service :
(i) Interruption in service condoned under Rule 25*
(ii) Extraordinary leave not qualifying for pension
(iii)Period of suspension not treated as qualifying.
(iv) Any other service not treated as qualifying
:
17. Emoluments reckoning for Gratuity
:
18. Average emoluments “emoluments drawn during the last ten months of service:
Post held From To Pay Personal or Special Pay
19.
(i) In a case where the last ten months include
some period not to be reckoned for calculating
average emoluments, an equal period backward
has to be taken for calculation average
emoluments.
(ii) The calculation of average emoluments should
be based on actual number of days in each
month.
(*Tamil Nadu Pension Rule 1978)
Date on which Form 5 has been obtained from the
Government servant (to be obtained on year before
the date of retirement of Government servant)
:
20. Proposed pension.
:
21. Proposed death-cum-retirement Gratuity.
:
22. Date from which pension is to commence.
:
23. Proposed amount of provisional Pension if
department or judicial proceeding is instituted
against the Government Servant before retirement.
:
24. Details of Government dues referred to in rule 70
recoverable out of gratuity.
:
25. Whether nomination made for :
(i) Death-cum-Retirement gratuity.
(ii) Non-contributory family pension, if
applicable.
:
26. Whether contributory family pension applies to the
government servant and if so:
(i) Emoluments reckoning for the family
pension.
(ii) The amount of the family pension
becoming payable to the family of the
government servant, if death takes place
after retirement.
(iii)Complete and up to date details of the
family as given in Form 3
:
Serial
Number
Name of the family members Date of birth Relationship with the
Government Servant
1 2 3 4
1. 2.
3. 4.
27. Height
:
28. Identification marks
:
29. Place of payment of pension (Treasury, Sub-
Treasury or Pay and Accounts Office)
:
30. Head of account to which pension and gratuity are
debitable.
:
:
Signature of the
Head of Office
FORM 1-A
FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF SUPERANNUATION PENSION WITHOUT MEDICAL
EXAMINATION WHEN APPLICANT DESIRES THAT THE PAYMENT OF THE COMMUTED VALUE OF PENSION SHOULD BE AUTHORIZED THROUGH THE PENSION PAYMENT ORDER
[see Rule 5(2), 12,13(30,14(i) and 15(3)]
(To be submitted in duplicate at least three months before the date of retirement)
PART I
To, (Here indicate the designation and full address of the Head of Office)
Subject : Commutation of pension without medical examination. Sir, I desire to commute a fraction of my pension in accordance with the provisions of the Central Civil Services (Commutation of Pension) Rule, 1981. The necessary particulars are furnished below-
1. Name (in Block letters)
2. Father’s name (and also husband’s name in the case of a female Government Servant)
3. Designation
4. Name of Office/Department/Ministry in which employed
5. Date of Birth (by Christian era)
6. Date of retirement on superannuation or on the expiry of extension in service granted under FR 56 (d)
7. Fraction of superannuation pension proposed to be commuted (The applicant should indicate the fraction of the amount of monthly pension subject to be maximum of forty percent thereof which he/she desires to commute and not the amount in Rupees)
8. Disbursing authority from which pension is to be drawn after retirement (score out which is not applicable)-
(a)
Treasury/Sub-treasury (name and complete address of the Treasury/Sub-Treasury to be indicated)
(b) (i) Branch of the nominated nationalized bank with complete postal address. (ii)Bank Account No. to which monthly pension is to be credited each month.
( c) Account Office of the Ministry/Department/Office
Signature
Present Postal Address
Postal address after retirement
Place :
Date :
Footnote : 1. The applicant should indicate the fraction of the amount of monthly pension (subject to a maximum of one-third thereof) which he/she desire to commute and not the amount in rupees. 2. Score out which is not applicable.
PART II
(ACKNOWLEDGEMENT)
Received from Shri/Smt/Kumari
(Name)
(designation)
Application in Part I of Form I-A for commutation of a fraction of pension without medical examination.
Place :
Signature Head of Office
Date :
NOTE – If the application has been received by the Head of Office before the date of retirement on superannuation, this acknowledgement should be detached from the Form and handed over to the applicant, If the form has been received by post, it has to be acknowledged on the same day and the acknowledgement sent under registered cover to the applicant. In case it is received after the specified date, it should be accepted only if it has been put into the post on or before that date subject to the production of evidence to that effect by the applicant.
PART III
Forwarded to the Account Office,
(here indicate the address and designation With the remarks that-
(i) the particular furnished by the applicant in Part I have been verified and are correct; (ii) the applicant is eligible to get a fraction of his pension commuted without medical examination; (iii) the commuted value of pension determined with reference to the table applicable at present comes
to Rs. and
(iv) the amount of residuary pension after commutation will be Rs.
2. The pension papers of the applicant completed in all respects were forwared under this Ministry
Department/Office Letter No. Dated
It is requested that the payment of commuted value of pension may be authorized the Pension payment Order which may be issued one month before the retirement of the applicant.
3. The receipt of Part I of this Form has been acknowledged in Part II which has been forwarded separately to the applicant on
4. The commuted value of pension is debitable to Head of Account
Place :
Signature Head of Office
Date :
FORM – 5
[(See Rules 39(I) (e) and 01(I)]
Particulars to be obtained by the Head of office from the retiring Government servant eight months the date of his
retirement:
1. Name ………………………………………………. 2. (a) Date of birth ………………………………………………. (b) Date of retirement ……………………………………………….
© H.R. No. …………………………………………………
(d) PAN NO. …………………………………………………
(e) Aadhar No. ……………………………………………………
(f) Mobil No. …………………………………………………….
(g) E-mail Add. …………………………………………………….
Two specimen signature ( to be furnished in a separate sheet ) duly attested by a Gazetted Govt. Servent -
Three copies of passport size joint photographs with wife or husband (to be attested by the Head of the office) – 3. Two slips showing the particulars of height and personal identification marks duly attested by a Gazetted
Government Servant -
5. Present address
6. Address after retirement
7. Name of the Treasury or the Branch of Public Sector Bank or the Pay and Accounts office through which the
pension is to be drawn. : 8. Details of the family in Form- 3
Place: Signature :
Date : Designation :
Ministry / Deptt / Office : BSNL
1. Two slips each bearing the left-hand thumb and a person whom is not literate to sign his name may furnish
finger impression duly attested. If such a Govt Servant on account of physical disability is unable to give left
hand thumb and finger impression he may give thumb and finger impression of the right hand. Where a Govt.
Servant have lost both of the hands he may give his toe impressions. A Gazetted Govt. Servant may attest
impressions.
2. Two copies of the pass port size photograph of self only need be furnished.
(i) If the government servant is governed by the rule 54 of the Central Civil Services (Pension), 1972 and he is
unmanned or a widower or widow.
(ii) If the Govt. Servant is governed by rule 55 of the Central Civil Services (Pension), 1972.
3. Where it is not possible for a Govt. Servant to submit a photograph with his wife or her husband, he or she may
submit separate photograph. The head of office shall attest the photograph.
4. Specify a few conspicuities marks not less then two if possible.
FORM – 3
DETAILS OF FAMILY
Name of Government Servant Designation Date of Birth Date of Appointment Details of member of my family* as on
Sl. No. Name of the Members of Family Date of Birth Relationship
with the official
Initial of the Head of
Office
Remarks
I hereby undertake to keep the above particulars up-to-date by notifying to audit officer/Head of office any addition
or alteration.
Place : Signature of the Govt. Servant :
Date :
Designation :
(a) PAN NO.
(b) Aadhar No.
(c) Mobil No.
(d) E-mail Add.
*Family for this purpose means:
1. Wife, in the case of male Government Servant
2. Husband, in the case of female Government Servant
3. Sons below eighteen years of age and unmarried daughter below twenty years of age including such son or
daughter adopted legally before retirement.
NOTE : Wife and husband shall include respectively judicially separation of wife and husband.
FORM
[SEE RULE 53(I)]
NOMINATION FOR DEATH-CUM RETIREMENT GRATUITY
When the Govt. Servant has a family and wishes to nominate one member, or more than one member, thereof.
I, ………………………………..…. hereby nominate the person (s) mentioned below, who is /are member (s) of my family
& confer on him / her right to receive to the extent specified below any amount that may be sanctioned by the Central
Government under the Central Government Employee Group Insurance Scheme 1980 in the event of my death while in
service or which having become payable on my attaining of superannuation unpaid at my death.
Original nominee (s) Alternate nominee (s)
Name and Address of the
nominee/ nominees
Relations
hip with
the
Governm
ent
Servant
Age Amount
of share
of
Gratuity
payable
to each
Name, address, Relationship of
person if any, to whom the
right conferred on the nominee
shall pass in the event of the
nominee pre –deceasing the
Govt. Servant or nominee
dying after the death of the
Govt. Servant but before
receiving payment of Gratuity
Dat
e of
Bir
th
Amount of
share of
gratuity
payable to
each
(1) (2) (3) (4) (5) (6) (7)
This nomination supersedes the nomination made by me earlier , which stands cancelled.
Note :
(i) The Government Servant shall draw lines across the blank space below his last entry to prevent the insertion
of any name after he has signed
(ii) Strike out which is not applicable.
Dated the :
Signature of two witnesses:
1 …………………………
2 …………………………
Signature of Government Servant
(To be filled by the Head Office)
Nomination by ……………………….. Signature of Head Office
Designation ………………………….. Date ……..
Office …………………………….. Designation ………………
FORM NO. 8
NOMINATION FOR BENEFITS UNDER CENTRAL GOVERNMENT EMPLOYEES GROUP INSURANCE
SCHEME, 1980
(When the Government Servant has a family and wishes to nominate one member or more than one thereof)
I, GIRISH KUMAR SINGH hereby nominate the person (s) mentioned below, who is / are member (s) of my family &
confer on him / her the right to receive to the extent specified below any amount the may be sanctioned by the Central
Government under the Central Government Employees Group Insurance Scheme, 1980 in the event of my death while in
service or which having become payable on my attaining age of superannuation may remain unpaid at my death.
Name and address of nominee (s) Relationship
with Govt.
Servant
Age *Share
to be
paid in
each
Contingencies on
the happening of
which the
Nomination shall
become invalid
Name. address and
relationship of the person if
any, to whom the right of the
nominee shall pass in the
event of his predeceasing
the Govt. Servant
(1) (2) (3) (4) (5) (6)
N.B. The Government Servant should draw line across the blank space below his last entry to prevent insertion of any
names after he has signed.
Dated the
Signature of two witnesses:
1. ……………………….
2………………………
Signature of the Government Servant
*This column should be filled in so as to cover the whole amount that to be payable under that insurance scheme.
FORM – 5
(See Rule 7)
Head of Office :
I, ……………………………….. (Name of the pensioner in Capital letters) hereby nominate the person named below,
under Rule 7 of Central Civil Services ( Commutation of Pension ) Rules, 1981.
Name and address of
nominee
Relationsh
ip with the
pensioner
Date of
Birth
If nominee is minor Relations
hip with
the
pensioner
Date of
birth if the
other
nominee is
minor
Name & Address
of person who
may receive the
said commuted
value during the
nominee’
minority
Name & Address of
nominee in case the
nominee under
column (i)
predeceases the
pensioner
1 2 3 4 5 6 7
Place :
Date :
Witness Signature:
Name and address :
Signature (or thumb impression if illiterate) and
Name of pensioner :
Address:
Signature of Head of Office
Stamp
Acknowledgement to be sent by the Head of Office
Certified that the nomination has been received from …………………………… ……(Name of pensioner) whose address is
………………………………………………
Place ………………
Date …………..
Signature of Head of Office
Full Address
[G.I.] Dept of Pension and Pensioners’ Welfare Nomination No. 34(5)/83-Pension Unit, date the 17th April, 1985, published
as SO 1870 in the Gazette of India dated the 4th May, 1985]
FORM – A
(See Rule 5)
Pension Disbursing Authority /Head of Office:
(Name of Bank /Treasury/Post Office/Account Officer etc)
I, ……………………………………. (Name of the pensioner in Capital letters) hereby nominate the person named below,
under Rule 5 of the payment of Arrears of Pension (Nomination) Rule, 1983.
Name and address of
nominee
Relations
hip with
the
pensioner
If nominee is minor Name and Address of
nominee in case the
nominee under
column (1)
predeceases the
pensioner
Relationship
with the
pensioner
Date of
birth if the
other
nominee is
minor
Date of
birth
Name and
Address of
person who
may receive
the said
commuted
value during
the nominee’s
minority
Place : Date :
Witness Signature :
Name and address:
Signature (or thumb impression if illiterate) and
Name of pensioner : Address:
Signature of Pension Disbursing Authority / Head of office
Stamp
Acknowledgement to be sent by the Head of Office
Certified that the nomination has been received from Shri ----------------------- (Name of pensioner) whose address is --------
-------------------------------------------------------------------------------------------
Place : ………………………
Date : ………………………
Signature of Pension Disbursing
Authority/Bank/Treasury/Post Office/Account Officer,
Head of Office
Full Address
FORM OF NOMINATION FOR G.P.F.
I hereby nominate the person mentioned below, who is a member of my family as defined in Rule 2 of G..P.F. (CS) Rule,
1960 to receive the amount that may stand to my credit in the fund in the event of my death before that amount has become
payable or having become payable has not been paid.
Name and Address of
nominee
Relationship
with
Subscriber
Age Contingencies on the
happening of which the
nomination shall become
invalid
Name of the person/persons, if any to
whom the right of the nominee shall pass
in the event of his predeceasing the
subscriber
Dated : at
Attested by Head of Office
Signature of subscriber
GPF A/C No.
Accepted
Account Officer
Bharat Sanchar Nigam Limited (A Govt. of India Enterprise)
(In duplicate)
Height and identification mark details of Shri
Height
Identification Mark
Attested by
Bharat Sanchar Nigam Limited (A Govt. of India Enterprise)
(In duplicate)
Specimen Signature of Shri
1 ……………………….
2 ……………………….
3 ……………………….
Attested by
Passport Size Photograghs with wife ( ATTESTED)
1. Photograph of Shri…………………………………with wife H.R. No……………….
Photograph Attested by
2. Photograph of Shri…………………………………with wife H.R. No……………….
Photograph Attested by
2. 3. Photograph of Shri…………………………………with wife H.R. No……………….
Photograph Attested by
भविष्य निधि
भविष्य निधि खाते में शेष रकम के अंनतम भुगताि हेतु आिेदि – पत्र का प्रपत्र
सेवा में, लेखाधिकारी(कैश), कार्ाालर् मुख्र् महाप्रबंिक दरूसंचार, (पूवी) पररमण्डल उ०प्र० हजरतगंज लखनऊ ।
महोदर्, मै ददनांक ......................... अपराहन को सेवाननवतृ्तत हो जाऊँगा । जन्मनतधि ...................
अतः ननवेदन है कक ननर्मानुसार ब्र्ाज सदहत मेरे खाते में जमा कुल िनराशश का मुझ ेभुगतान करने कक कृपा करें ।
मेरी भववष्र् ननधि खाता संख्र्ा ..............................एवं एच० आर० नं० ............................ है । मै अपने कार्ाालर् कार्ाालर् मुख्र् महाप्रबंिक दरूसंचार, पूवी उ०प्र० पररमण्डल लखनऊ के माध्र्म से भुगतान प्राप्त करना चाहता हँू ।
मेरे व्र्त्ततगत पहचान वववरण बार्ें हाि के अगूंठे के अिवा अगंुशलर्ों के ननशान (ननरक्षर अशंदाता) के मामले में तिा नमूने के हस्ताक्षर ( साक्षर अशंदाता के मामले में ) तिा सरकारी राजपत्रित अधिकारी द्वारा ववधिवत सतर्ावपत कराकर दो प्रनतर्ों में संलग्न है ।
स्िान : आपका
हस्ताक्षर
ददनांक : नाम.................................................................. पता.................................................................. फोन/ मोबाइल नं०..............................................
कृपया पेंशि प्रपत्र के साथ निम्ि लिखखत दस्तािेज संिग्ि करे
1- 06 फोटो साइज 5X8.5cm ( लसगंि/ज्िाइंट) जो भी हो । 2- आिार कार्ड ि पैि कार्ड की दो-दो प्रनतयााँ स्िप्रमाखित (पनत ि पत्िी दोिो की )
3- राष्रीयकृत बैक में खाता ि कैं लशि चेक हस्ताक्षर सहहत दो प्रनतयो में ।
4- CCA द्िारा जारी िामांकि पत्र फामड 1,2, ि 3 पूिड रूप से भर कर सक्षम अधिकारी से सत्यावपत करिा कर दो प्रनतयम में
5- VRS request and accepting letter.
P & GS MANDATE
ELECTRONIC MODE APPLICATION FORM To
The P & GS Unit Office
_________________________________ Luck now. Sub: Mandate for Electronic Mode
Sir, I/We give below the details required for payment through Electronic Mode. (Please √ appropriate item) (1) Master Policy No. / Annuity No.________________________________________ (2) Name of the Master Policy holder /Annuitant : _____________________________ (3) Bank Name : ______________________________________________________ (4) Bank Address : _____________________________________________________ (5) Account Type : Savings/Current/Cash Credit____ __________________________ (6) Account No. (7) IFS Code of the Bank : (8) MICR Code of the Bank :
(9) Contact Mobile No. : (10) E-Mail Id : _________________________________________________________
Kindly transfer amount due under the above Master Policy / Annuity. The following documents are enclosed as required. (Please √ appropriate item)
A. Cancelled cheque leaf
B. Photo copy of the first page of Bank pass book containing details (If cheque is not having the name of account holder)
_____________________
Signature Date :
FOR OFFICE USE ONLY
1) Name & SR No. of the Person Entering the data : 2) Date of Entry : 3) Name & SR No. of the Person validating : 4) Date of Validation :
+ 9 1
Life Insurance Corporation of India
(Established by the Life Insurance Corporation Act. 1956)
Divisional Office : Luck now
MASTER POLICY No……………….. CLAIMENT’S AND EMPLOYER’S STATEMENT
Part 1 : CLAIMNT’S STATEMENT
(To be completed by the Master Policyholder i.e. by Trustees of the scheme in the case of Group Gratuity &
Superannuation Schemes & by the Employer in case of other Group Insurance Schemes )
1. (i) Name of the Scheme
(ii) Master Policy No.
(iii) Full Name and address of
The Master Policyholder
2. (i) Full Name of the
deceased Member
(ii) Serial No. of the deceased in the
date for the policy year in which death
occurred .
3. (i) Date of entry into
Scheme by Member
(ii) Date of death of Member
(iii) Cause of death of Member
We hereby declare that the answers to all the above questions are true in every respect.
We enclose……………………………………….in original in proof of death of the Member.
PLACE……………………… (Signature of Master Policyholder)
DATE……………………… SEAL:
Please Specify the nature of proof submitted.
Life Insurance Corporation of India Part II : EMPLOYER’S STATEMENT
(To be completed by the Employer in a case where no individual evidence of health was obtained during
3 years prior death )
1. Name of the Employer:
2. (i) Full Name of the deceased Member.
(ii) Serial No. of the deceased in the data
for the policy year in which death occurred.
(iii) Date of entry into service.
(iv) Date last attended duties prior to Death.
(v) Date of Death.
(vi) Cause of Death.
(vii) Place of Death.
(viii) Was the member in the service of the
Employer on the date of death ?
(ix) Date of Birth.
Please give below the record of absences from duty by Member during the past 3 years prior to death :
Period No. of Nature of Leave reason as stated Remarks
From To days in Application Form
Please state whether Doctor’s Certificate was submitted in case of leave on grounds of health.
We hereby declare that the answers to all the above questions are true in every respect.
PLACE……………………… (Signature of Master Employer)
DATE……………………… SEAL:
ANNEXURE 1
Pensioner’s letter of Authority and Undertaking To, Date----- Pr.CCA/CCA ………………….. Sir,
I hereby opt to draw my Pension through a Bank Account under the direct disbursement of telecom pension by DOT through SAMPANN. I hereby authorize the bank to receive my monthly Pension on my behalf and credit the same to my account as per particulars given as follows:
a. Name of the Bank : b. Branch : c. Account No. : d. IFSC Code :
2) I hereby undertake that any amount of excess/wrong payment of pension, if credited to my Bank Account will be refunded on your instructions.
3) I undertake and agree to bind myself and my heirs, successors, executors and administrators to
indemnify the Bank/ PDA in so crediting my pension to my account under the scheme and to forthwith refund/pay any amount due from me to the Bank/PDA and also irrevocably authorize the Bank/PDA to recover, any amount due from me by debit to my said account or any other accounts/deposits belonging to me in possession of the Bank.
----------------------------------------------------
Signature of Pensioner Witnesses :- (1) Signature : (2) Signature : Name : Name : Address : Address :
1. Personal details:-
1. Name of the Pensioner : 2. Designation : 3. Date of retirement : 4. Address of the Pensioner :
Family Pensioners only:-
5. Relationship with deceased : 6. Name of the Family Pensioner :
2. Bank Details :-
1. Saving /Current Account No. : 2. Name of the Bank : 2. Name of the Branch :
3. (a) Certified that the Bank details (2 above) are correct. The account of pensioner and his/her signature given overleaf agrees with the specimen signature held in our records. (b) Any excess amount credited in the account of the pensioner and due/refundable to the PDA will be refunded immediately as and when called for by the PDA. Notwithstanding anything contained in this clause 3(b), the Bank and the PDA agree and understand that the obligation cost on the Bank by medium of this clause[3(b)], shall be subject to:- i. The rights conferred and the duties imposed on the Bank by Law and/or norm and/or regulations. Place : Signature of the Bank Manager Date : (Bank Accounts Seal)
• Note – Part 1 & 2 to be filled in by the pensioner and Part 3 by Bank.
MANDATE FORM
I, hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incompleteness or incorrectness of information given by me as above, I would not hold the user institution responsible. Dated ……………..
(Signature of Spouse) (Signature of the Beneficiary)
Certified that the particulars furnished above are Correct as per the record.
Bank Stamp (Signature of the Authorised officer )
Dated
1. Beneficiary Name
2. Beneficiary/Address &Telephone No.
3. Beneficiary Account No.
4. Account type ( Saving/Current for Cash Credit)
5. Nine digit code number of the Bank & branch appearing on the MICR Cheque issued by the bank (if available)
6. Bank Name
7. Branch Name & Address with Telephone No.
8. IFSC (Indian Financial Services Code)
9. Photo copy of the cancelled cheque to confirm correctness of IFSC code and Account No. given
PERSONAL IDENTIFICATION MARK OF SPOUSE OF
SRI/SMT ……………………………………… …….
SRI/SMT………………………………………………………..
Height……………………………………………………………
Identification Mark……………………………………………
Blood Group…………………………………………………….
SIGNATURE…………………………………………………….
Name of the employee
Signature of the employee
HR No.
LETTER OF UNDERTAKING Date: ……………..
To Under Secretary (STP), DoT, New Delhi/Pr.CCA/CCA ………………………………………………………..
(Strike out whichever is not applicable)
(Through O/o ……………..BSNL………………..)
Ref: (i) DoT letter No. 40-12/2004-Pen(T)(pt.) dated 17-05-2018 & (ii) BSNL C.O. letter No. 48-11/2017- Pen (B) dated 30-05-2018 Sir,
I, Shri ……………………… ………. , Desgn. …… , O/o …………………
hereby undertake that in case the court case(s) filed against the DoT order no. 40-12/2004- Pen
(T)(Pt.) dated 05.7.2017 are decided in favour of this DoT order, I shall refund the over-
paid amount on account of grant of an extra-increment on the post based promotion under the
Executive Promotion Policy(EPP) of BSNL.
Yours faithfully,
Sign............................................ Name……………………………. Designation………………….......
Office……………………………. ………………………………
Residence Address……………………… ………………………….
Mob. No……………….. Landline……………….
Annex-III
UNDERTAKING
In accordance with BSNL CO. ND 1 letter no 412-24/2011-Pers.I dtd 11.8.2011
I hereby undertake that I have not filed any Court Case i.r.o Adhoc Promotions
And Subsequent Regular Promotions.
I hereby undertake to Refund any excess payment that may be found to have been made as result
of outcomes of various Court Cases incorrect fixation of pay or any excess payment detected in the light
of discrepancies noticed subsequently including reduction of Pension /Pensioner benefits to the
Government either by adjustment against future payments due to me or otherwise.
Signature:……………………………………………
Name:……………………………………………......
Designation:………………………………………....