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53
For Office Use
INSTRUCTIONS REGARDING GRANT
OF TIMELY EX-GRATIA BENEFITS
TO THE FAMILY OF DECEASED
UNIVERISTY EMPLOYEES
CHAUDHARY CHARAN SINGH
HARYANA AGRICULTURAL UNIVERISTY
HISAR
2010
54
PREFACE
In order to make timely payment of ex-gratia benefits to the family of deceased
University employees, instructions have been issued from time to time by the
University. However, for sometime past, it was felt that these payments get delayed
due to one reason or the other and for want of readily available instructions. So, it
became necessary to have instructions as well as procedure to be adopted in this regard
may be compiled in a booklet form. Accordingly, the present booklet titled as
“Instructions regarding grant of timely Ex-gratia Benefits to the Family of Deceased
University Employees” has been brought out, which contains the time schedule as well
as procedure for releasing ex-gratia benefits such as; EWF, GSLIS, Ex-gratia, Death-
cum-Retirement Gratuity, Leave Encashment, Compassionate Financial Assistance,
Final Payment of CPF/GPF and Family Pension (if the deceased employee was in
pension scheme). This booklet will serve as a guide and handy reference book to the
Heads of the Departments/Offices as well as other concerned offices for releasing
timely payment of ex-gratia benefits to the family of deceased University employees.
I appreciate the efforts made by Sh. M. L. Munjal, Dy. Comptroller (Budget)
and the assistance of computer typing extended by Sh. Krishan Munjal, Sr. Scale
Stenographer and Mrs. Neelam Arora, Jr. Scale Stenographer in the compilation of
this important booklet.
June, 2010 (K. S. Khokhar)
Vice-Chancellor
55
INDEX
Sr.
No.
Particulars Page
No.
1. Details of payments to the bereaved families 1
2. Time Schedule for payments 1-3
3. Position and the attachments/documents required in each case of
assistance
3-8
4. Pre-requisites for payments 9-11
5. Application/proposal for release of assistance out of EWF 12-13
6. Application/proposal for release of payment of GSLIS 14-16
7. Application/proposal for Ex-gratia grant 17-20
8. Application for payment of Leave Encashment 21
9. Application/proposal for release of Death-cum-Retirement Gratuity 22-24
10. Application/proposal for Compassionate Financial Assistance 25-27
11. Application/proposal for Final Payment of CPF/GPF 28-31
12. Family Pension Form Set 32-52
1
Payments to bereaved families
It has been observed that the financial assistance to the families of the
employees dying while in service is not being provided in time. So to avoid
unnecessary delay and to render financial assistance to the bereaved family in
time, the University has been nominating/appointing Sr. Welfare Officer and
Welfare Officer every year amongst the teachers and the employees of the
University for the last several years. The job of the Welfare Officers is as
under : -
(i) To assist the bereaved families without any inhibition and in a spirit of
social service.
(ii) To ensure that all formalities regarding final payments due to the families
of the deceased employees are got completed and cases got processed
expeditiously.
(iii) To visit the families to render all possible help wherever feasible.
2. The Welfare Officers are required to be given intimation about the unfortunate
incident immediately so that all possible necessary assistance is rendered timely.
3. The bereaved family is provided the following assistance :-
I. Employees Welfare Fund (EWF)
II. Group Saving Linked Insurance (GSLI)
III. Ex-Gratia Grant
IV. Leave Encashment
V. Death-cum-Retirement Gratuity (DCRG)
VI. Compassionate Financial Assistance
VII. Final Payment of CPF/GPF
VIII. Family Pension (if the employee was in the Pension Scheme)
4. Time Schedule
(A) Head of Deptt./office/Section
To ensure the timely release of all payments on account of the above, the time
schedule has been laid down for the various Deptts./offices as under :-
Sr.
No.
Particulars Time prescribed
(i) Head of Deptt./Section, on the receipt of intimation
regarding the death of an employee, will inform the
Registrar, Comptroller, Controlling Officer and the Sr.
Welfare Officer/Welfare Officer
Same day
2
Sr.
No.
Particulars Time prescribed
(ii) (a) He will obtain the ‘No Dues Certificate’ (NOC)
from all concerned.
(b) Simultaneously, he will obtain the
requests/applications except of family pension
(complete in all respect) from the nominee/legal
heir of the deceased employee in respect of the
above mentioned assistance. For this purpose, the
HOD/Incharge will depute an official to get the
necessary forms filled if the family of the
deceased employee is at headquarter. If the
family of the deceased employee is living at
outstation, he will send the necessary
applications/forms alongwith detail of the pre-
requisite documents, by post (Registered) for
furnishing the same.
(c) If there is any delay in submitting the application
and furnishing the desired information by the
family of the deceased employee, HOD/ Incharge
will also send the necessary information to the
Sr. Welfare Officer/Welfare Officer/Controlling
Officer/Comptroller/ Registrar
Within 15 days
(iii) Thereafter, he will submit all the cases (except of family
pension) with the service book/personal
file/NOCs/CR/SAR file with a single note to the
Controlling Officer for sanction/onward transmission to
the Comptroller & Registrar as under :-
Within 7 days
(a) EWF, GSLIS, Ex-gratia, DCRG, Final Payment of
CPF/GPF to the Comptroller.
(b) Compassionate Financial Assistance to the Registrar
(c) Leave encashment : to be sanctioned by the
HOD/Controlling Officer as per their competency)
(iv) He will make/ensure the payment of leave
encashment/DCRG after its sanction by the competent
authority
Within 7 days
3
Sr.
No.
Particulars Time prescribed
(v) Before completion of admissible period of
Compassionate Financial Assistance, the HOD/Incharge
will process the case of Family Pension due to the
bereaved family
6 months prior to
the completion of
Compassionate
Financial
Assistance
(B) Controlling Officer
On receipt of the cases, he will scrutinize them and forward the
cases of EWF, GSLIS, Ex-gratia, DCRG, Final Payment of
CPF/GPF to the Comptroller while the case for grant of
Compassionate Financial Assistance to the Registrar. He will
forward the case of Compassionate Financial Assistance with an
attested copy of the service book of the deceased employee,
while the case of leave encashment, after sanction, will be
returned to the Deptt./office.
Within 15 days
(C) Comptroller
On receipt of the cases, he will deal/process all the cases and
will ensure the payments (except of GSLIS as in this case the
payment is to be released by the LIC).
Within 15 days
(D) Registrar
On receipt of the case of Compassionate Financial Assistance,
he will process and obtain the approval.
Within 15 days
(E) Sr. Welfare Officer/Welfare Officer
Sr. Welfare Officer/Welfare Officer will pursue and ensure the
release of all the payments/dues to the nominee/legal heir of the
deceased employee timely. He will report the delay, if any, in
release of the payments to the Registrar.
Within 15 days
5. In case of late payment of dues to the bereaved family, responsibility will be
fixed by the HOD/Officer concerned/Registrar. The defaulter will be fined @
Rs.100/- per day. If the delay is more than one month, disciplinary proceedings
will be initiated against the defaulter.
6. The position in brief and the attachments/documents required in each case of
assistance is as under :-
I. Employees Welfare Fund:
(a) Out of this fund, the Monetary aids are provided to the family of
deceased in case of his death. An amount of Rs. 7500/- is given
immediately within 15 days of occurrence of the death of the
employee out of this fund on the request of the legal heir/nominee.
4
(b) Financial assistance on the basis of rate of contribution by the
employees is given as under : -
(Amount in Rs.)
S.
No.
Rate of contribution per
month
Amount of financial
assistance admissible out
of EWF
1. 15/- 35,000/-
2. 30/- 70,000/-
3. 60/- 1,40,000/-
4. 90/- 2,00,000/-
The amount of Rs. 7500/- as mentioned in (a) above is reduced
from the quantum of financial assistance admissible as mentioned
above.
II. Group Saving Linked Insurance Scheme (GSLIS):
According to this scheme, a portion of premium charged is set aside for
insurance cover in the event of death and the balance is put into saving
bank account of each member with interest. Out of every Rs. 10/-
collected, about Rs. 3.75 are appropriated towards risk cover premium
and the balance amount of about Rs. 6.25 is credited to the saving
account. The monthly contribution payable by the employee and the
amount of the insurance cover is as under: -
S. No. Category of employee Monthly premium Maximum cover
1. Class-I 100 1,00,000/-
2. Class-II 60 60,000/-
3. Class-III 30 30,000/-
4. Class-IV 15 15,000/-
The above rates have been revised w.e.f. 7/09 payable in 8/09, the revised
rates of monthly contribution and the amount of insurance cover is as
under :-
S. No. Category Revised Monthly
premium
Maximum cover
1. Class-I 180 1,00,000/-
2. Class-II 108 60,000/-
3. Class-III 54 30,000/-
4. Class-IV 27 15,000/-
5
According to the above, the insurance cover & saving portion is on 50 :
50% basis which are payable in the event of the death of the employee
(i) In the event of death of an employee, the insurance cover as
applicable to respective category would be paid to his beneficiary.
In addition, amount accumulated in the savings with interest in
respect of the deceased employee upto the date of death would also
be paid to his beneficiary.
III. Ex-gratia grant/payment:
In the event of death of the employee, Ex-gratia grant maximum of
Rs. 25,000/- is given to the dependent of the deceased employee.
IV. Leave Encashment :
The payment in lieu of unutilized earned leave at the credit of the
employee on the day of death is granted. This leave encashment is paid in
lumpsum as a one time settlement and maximum of 300 days. This cash
payment for unutilized earned leave is made in the manner as under : -
Cash
Payment =
Pay+GP+DA as admissible
on date of death
30 x
Number of unutilized
days of earned leave
credit subject to a
maximum of 300 days
V. Death-cum-Retirement Gratuity : -
DCRG is granted to the dependent/nominated family member/legal heir
of the deceased employee. This gratuity is calculated as under: -
Last pay
drawn
(plus D.A.). x
4
1
x
Completed 6 monthly period subject to
maximum 66 times in case of Class-I, Class-II
and Class-III and 70 times in case of Class-IV
employees (Fraction of 3 months & more to be
counted half year).
Gratuity on death :
(i) 2 months emoluments If service is less than one year
(ii) 6 months emoluments If service is less than five years.
(iii) 12 months emoluments If service is five years to 24 years
period.
(iv) ¼ month emoluments for
each half year subject to a
maximum of 16½ months
(17½ months in case of Class
IV).
In excess of 24 years service.
6
The maximum limit of payable DCRG has been revised to
Rs. 10,00,000/- w.e.f. 1.1.2006.
VI. Compassionate Financial Assistance :-
The Govt. of Haryana has notified “Haryana Compassionate Assistance to
the dependents of deceased Government Employees Rules, 2006” to grant
compassionate assistance by way of ex-gratia financial assistance on
compassionate grounds to the members of the families of the deceased
Govt. employees who die while in regular service/missing. The Govt. of
Haryana instructions have been adopted by the University as such. The
object of the rules is to assist the family of a deceased/missing employee,
in tiding over the emergent situation, resulting from the loss of the bread-
earner while in regular service. On the death of an employee, the family
of the employee would continue to receive financial assistance a sum
equal to the pay and other allowances that was last drawn by the deceased
employee in the normal course without raising a specific claim as under :-
1 (a) for a period of fifteen years from the date of death of the employee,
if the employee at the time of his/her death had not attained the age
of thirty five years.
(b) for a period of twelve years or till the date the employee would
have retired from Government service on attaining the age of
superannuation, whichever is less, if the employee at the time of
his/her death had attained the age of thirty-five years but had not
attained the age of forty-eight years.
(c) for a period of seven years or till the date the employee would have
retired from Government service on attaining the age of
superannuation, whichever is less, if the employee had attained the
age of forty-eight years.
2. House Rent Allowance shall not be a part of allowance for the
purposes of calculation of assistance.
3. The family of a deceased Government employee who was in
occupation of a Government residence would continue to retain the
residence on payment of normal rent/license fee for a period of one
year from the date of death of the employee.
4. The eligibility to receive financial assistance under the rules shall
be as per the provision in the Pension/Family Pension Scheme –
1964.
5. The family shall be eligible to receive family pension as per the
normal rules only after the period during which he/she receives the
financial assistance as above is completed.
The request of the eligible nominee/legal heir of the deceased family will
7
be made in the prescribed Form as circulated by the Govt./University. On
the receipt of this form, the department shall prepare/send a case (after
getting the last salary drawn by the deceased employee duly verified from
the Audit) alongwith service book to the Registrar through Controlling
Officer for obtaining the necessary orders of the competent authority and
issuing the orders so that the payment shall be released by the department.
The payment will be released within one month by the department/office
concerned. In case of inordinate delay, the responsibility will be fixed and
necessary action will be initiated against the official at fault.
VII. Final payment of C.P.F./G.P.F. :-
When a subscriber dies, the amount standing to his credit in the General
Provident Fund/Contributory Provident Fund is paid to his dependents.
The interest shall be paid on the amount upto the end of twelve months
after the month in which the amount becomes payable.
As per the rules, the final payment of CPF/GPF can be drawn by the legal
heir/nominee of the deceased employee after producing No Objection
Certificate from all concerned. The request will be made in the prescribed
form. Thereafter, the HOD will send the case in the prescribed Form after
furnishing the complete information through the Controlling Officer to
the Comptroller for final payment. This case will be supported with the
service book and the copies of the NOC from all concerned. The service
book should also contain the entry of the death of the employee as well as
having obtained the NOC from all concerned. This entry should be duly
attested/verified by the DDO/HOD concerned and the Audit.
VIII. Family Pension (If the employee is/was in the Pension Scheme) :-
Under Haryana Civil Services (Revised Pension) Part-II Rules, 2009, in
case of death of an employee during service, if the service is more than
one year but less than seven years, then minimum Rs.3500/- p.m. pension
is admissible to his/her family w.e.f. 01.01.2006. If service is more than 7
years, the family would get Enhanced Family Pension at the rates of
pension what the employee would have drawn had he superannuated on
attaining the age of 60 years at the pay drawn on the date of death while
in service. This Enhanced Family Pension would be for 10 years after the
completion of period of Financial Assistance. After that, the family would
get normal family pension at the rate of 30% of basic pay of employee.
Definition of family for entitlement of family pension
(i) For the purposes of grant of family pension, the term ‘family’ shall
be categorized as under : -
Category-I
(a) widow or widower, upto re-marriage, or, as the case may be,
8
death if the recipient remains un-married till death;
(b) son/daughter (including widowed daughter), upto the date of
his/her marriage/re-marriage or till the date he/she starts
earning or till the date he/she attains an age of 25 years,
whichever is the earliest.
Category-II
(a) unmarried/widowed/divorced daughter, not covered under
Category-I above, till the date of marriage/re-marriage or till
the date she starts earning or till the date of death, whichever
is earlier;
(b) parents who were wholly dependent on the Government
servant when he/she was alive provided the deceased
employee had left behind neither a widow nor a child.
(ii) Family pension to unmarried/widowed/divorced daughters in
Category II and dependent parents shall be payable only after the
other eligible family members in Category I have ceased to be
eligible to receive family pension and there is no other eligible
disabled child to receive the family pension. Grant of family
pension to children in respective categories shall be payable in
order of their date of birth and younger of them will not be eligible
for family pension unless the next above him/her has become
ineligible for grant of family pension in that category.
(iii) The dependency criteria for the purpose of family pension shall be
the minimum family pension of Rs. 3,500/- and dearness relief
thereon.
(iv) The childless widow of a deceased Government servant shall
continue to be paid family pension even after her remarriage
subject to the condition that the family pension shall cease once her
independent income from all other sources becomes equal to or
higher than the minimum prescribed family pension in the State
Government. In all such cases, the family pensioner would be
required to give a declaration regarding her income from all other
sources to the Pension Disbursing Authority every six months.
3. All the cases for grant of assistance as mentioned above will be prepared by the
concerned department/office where the employee was working and forwarded to
the competent authorities. All these cases will be initiated along with the request
of the dependent of the deceased family, death certificate, service book etc. of
the deceased employee. The pre-requisite for sanction of the above payments/
assistance out of various funds are detailed in the Annexure ‘A’.
9
ANNEXURE-A
PRE-REQUISITES FOR PAYMENTS
I. Employees Welfare Fund :
(i) Application from the nominated family member/legal heir.
(ii) Service book with entry of death of the employee duly attested/verified by
the DDO/HOD concerned and Audit.
(iii) Certificate from the DDO/HOD that the deceased was a regular subscriber
@ Rs.______ p.m. and when was the last deduction made duly verified by
the Audit.
(iv) Attested copies of the Death certificate and nomination form duly
accepted by the competent authority.
(v) Application with the recommendations of the HOD/Controlling Officer is
to be forwarded to the Comptroller for payment.
II. GSLIS :
(i) Application from the nominated family member/legal heir.
(ii) Service book with entry of death of the employee duly attested/verified by
the DDO/HOD and Audit
(iii) Original Death Certificate issued by the Registrar, Birth & Death
Registration Authority/competent authority.
(iv) Certificate from the DDO/HOD that the deceased was a regular
contributor towards GSLIS and that his name was sent to the
Comptroller’s office on 1st June while sending the list of employees to be
covered under GSLIS.
(v) Application in the prescribed proforma with the recommendations of the
HOD/ Controlling Officer is to be forwarded to the Comptroller for
payment.
(vi) Attested copy of the nomination form and the receipt of the nominee.
III. Ex-Gratia Grant :
(i) Application alongwith affidavit from the nominated family member/legal
heir.
(ii) Service book with entry of death of the employee duly attested/verified by
the DDO/HOD & Audit.
(iii) Confidential Reports File alongwith gist of the CRs/SARs of the deceased
employee.
10
(iv) Application in the prescribed proforma with the recommendations of the
HOD/ Controlling Officer is to be forwarded to the Comptroller for
payment.
IV. Payment of Leave Encashment :
(i) Application from the nominated family member/legal heir.
(ii) Service book with entry of death of the employee duly attested/verified by
the DDO/HOD & Audit.
(iii) No dues certificates may be obtained from the DEO, Nehru Library,
Faculty Club/Community Centre, Appointing authority, Bank concerned
(if loanee) and the Department and the entries thereof are also to be made
in the service book duly attested/ verified by the DDO/HOD & Audit.
(iv) Case with the recommendations of the DDO is to submitted for sanction
to the competent authority.
V. Payment of Death-cum-Retirement Gratuity :
(i) Application from the nominated family member/legal heir.
(ii) Service book with entry of death of the employee and all certificates
required for pension recorded in service book duly attested by the
DDO/HOD.
(iii) No dues certificates may be obtained from the DEO, Nehru Library,
Faculty Club/Community Centre, Appointing authority, Bank concerned
(if loanee) and entry thereof in the service book duly attested by the
DDO/HOD.
(iv) Original or attested copy of the death certificate and personal file.
(v) Recommendations of the HOD/Controlling Officer, if any deduction is
required to be made from the gratuity due to unsatisfactory work of the
official or any dues of the University made to the Comptroller for
sanction.
VI. Compassionate Financial Assistance :
(i) Application (alongwith death certificate) and an undertaking on affidavit
in view of employment/remarriage from the nominated family
member/legal heir.
(ii) Service book or attested photocopy thereof with entry of death of the
employee duly attested/verified by the DDO/HOD & Audit.
(iii) No dues certificates may be obtained from the DEO, Nehru Library,
Faculty Club/Community Centre, Appointing authority, Bank concerned
(if loanee) and the Department and the entries thereof are also to be made
in the service book duly attested/ verified by the DDO/HOD & Audit.
11
(iv) Detail of the last emoluments (Pay + GP + Allowances) drawn by the
deceased duly attested/verified by the DDO/HOD & Audit.
(v) Application, alongwith service book, No Objection Certificates from all
concerned alongwith recommendations of the Controlling Officer is to be
sent to the Registrar for necessary approval and issue of orders.
VII. Final payment of C.P.F./G.P.F. :-
(i) Application in the prescribed form (alongwith death certificate & two
attested photos, personal identification mark slip, two signatures duly
attested) from the nominated family member/legal heir.
(ii) Service book with entry of death of the employee duly
attested/verified by the DDO/HOD & Audit.
(iii) No dues certificates may be obtained from the DEO, Nehru Library,
Faculty Club/Community Centre, Appointing authority, Bank
concerned (if loanee) and the Department and the entries thereof are
also to be made in the service book duly attested/ verified by the
DDO/HOD & Audit.
(iv) Applications in the prescribed form alongwith service book duly
attested photocopy of nomination form, No Objection Certificates
from all concerned with the recommendations of the Controlling
Officer is to be sent to the Comptroller for payment.
VIII. Family Pension
(i) Application in the prescribed form (pension set) with the affidavits,
photos and death certificate from the nominated family member/legal
heir.
(ii) Service book with entry of death of the employee and all required
certificates for pension to be recorded in the service book duly attested
by the DDO/HOD.
(iii) No dues certificates may be obtained from the DEO, Nehru Library,
Faculty Club/Community Centre, Appointing authority, Bank
concerned (if loanee) and the Department and the entries thereof are
also to be made in the service book duly attested (verified by the
DDO/HOD & Audit).
(iv) Application, alongwith service book, No Objection Certificates from
all concerned alongwith recommendations of the Controlling Officer
is to be sent to the Comptroller for issue of PPO.
12
APPLICATION FOR RELEASE OF ASSISTANCE OUT OF
EMPLOYEES WELFARE FUND
1. Full information of the deceased University Employee :
(i) Name & Designation :
(ii) Deptt./office :
(iii) Date of Birth :
(iv) Date of joining of employee :
(v) Date of death (with proof) :
(vi) Pay scale :
2. Full information of Applicant/claimant
(i) Name :
(ii) Full Address :
(iii) Relationship with the deceased :
University employee
3. Any other information :
It is requested to release the assistance out of the Employees Welfare Fund as
per HAU rules.
Encl : Death Certificate
Place : Signature of the applicant
Date :
13
Subject : Grant of assistance out of Employees Welfare Fund (EWF) in respect of
Sh./Smt. ____________________________.
Sh./Smt. ____________________ S/o, W/o ______________________
was working as __________________________________ in this office/department.
Sh. Smt. ________________________ s/o, w/o late __________________________
has requested for grant of assistance out of Employees Welfare Fund (EWF). Late
Sh./Smt. ____________________ has expired on _____________ as per death
certificate issued by ___________________. As per nomination, the payment is to be
made to Sh./Smt._________ s/o, w/o of the deceased employee. The deceased
employee was contributing towards EWF @ Rs.___________ per month and last
deduction of EWF contribution was made from the salary in the month
of ___________ (to be got verified from the Audit). Therefore, the financial assistance
of Rs. _________ is admissible. An immediate assistance of Rs.__________ has
already been given to the family of the deceased employee. Therefore, full/balance
amount of Rs.___________ is payable to the nominee. The case is recommended and
forwarded to the Controlling Officer for onward transmission to the Comptroller.
Head of Department
(alongwith signature & stamp)
Controlling Officer
The above case has been checked and is in order. So the case of the nominee
of late Sh./Smt.__________ for making the payment of Rs._____________ on account
of financial assistance out of EWF is recommended and forwarded to the Comptroller.
Controlling Officer
(alongwith signature & stamp)
The case of __________ in respect of late Sh./Smt. _____________ for
making the payment of Rs. ____________ on account of financial assistance out of
EWF is in order and is submitted to the Comptroller for sanction/approval please.
14
APPLICATION FOR RELEASE OF PAYMENT OF GSLIS
1. Full information of the deceased University Employee :
(i) Name & Designation :
(ii) Deptt./office :
(iii) Date of Birth :
(iv) Date of joining of employee :
(v) Date of death (with proof) :
(vi) Pay scale :
2. Full information of Applicant/claimant
(i) Name :
(ii) Full Address :
(iii) Relationship with the deceased/ :
University employee
3. Any other information :
It is requested to release the payment of GSLIS as per HAU rules.
Encl : Death Certificate
Signature of the applicant
Place :
Date :
15
ANNEXURE-II
LIFE INSURANCE CORPORATION OF INDIA
Divisional Office KARNAL
GSLI CLAIM FORM B
(To be completed by the Master policy holder for claiming benefits under the Group
Savings Linked Insurance Scheme on death of a member)
1. Name of the Master Policy Holder COMPTROLLER,
CCSHAU, HISAR
2. Master Policy No. GSLI 67086
Date of commencement 20.08.1987
3. Full name of the deceased employee
4. Employee No./Sr. No. in the list of members
5. Date of birth
6. Date of joining service
7. Date of joining the scheme
8. Category/Salary Grade
9. Date of death
10. Amount of life insurance cover on the date of death
11. Amount of monthly contribution
Risk Portion
Savings Portion
12. If there has been any change/s in the monthly
contribution during his membership indicate the date of
change/s and the revised contribution/s
13. Amount of last monthly contribution
14. Due date for payment of the last monthly contribution
(indicate day-month & year)
15. The date on which the last contribution was paid to the
Corporation
16. Are there any gaps in premium and if so, give full
particulars thereof.
17. Cause of Death
18. Nature of proof of death (please enclose original death
registration certificate)
19. Was the member in the service of the employer on the
date of death
16
20. Name of the beneficiary and relationship with the
member
21. Additional information in case death has taken place within 3 years of date of
joining the scheme
(a) Was the member absent on the date of entry into the
scheme (if so, give details of leave i.e. period of absence.
Cause of absence, how the absence was treated by the
employer and date of resuming duties)
(b) Whether the contribution of the member was included in
the monthly remittance for the scheme as a whole in the
first month. Give details of amount and date of payment
to LIC
(c) The date of the Authority-cum-declaration form signed
by the employee
(d) Was the member alive on the date the salary was
disbursed and out of which the deduction of contribution
to the GSLI scheme to cover the first premium was made
by the employer.
We hereby declare that the answers to the above questions are true in every
respect and the deceased member was eligible for the above benefits as per the rules of
our GSLI Scheme and contributions were paid in respect of him strictly as per the rules
of the scheme.
Head of department
Controlling Officer
Dated at ________________ this _________ day of _____________________
WITNESS Signature of the
Master policyholder
Signature ___________
Name ______________
Address ____________
___________________
Detail of premium
17
CCS HARYANA AGRICULTURAL UNIVERSITY, HISAR
FORM OF APPLICATION FOR EX-GRATIA GRANT
PART-A
Application from the family of Late Dr./Sh./Smt._____________________
employed as _________________ in the office/deptt. of _______________________.
1. Name and full address of the applicant
2. Relationship to the deceased employee
3. Date of birth of the HAU employee
4. Name and age of surviving relation of deceased
a) Widow/husband
b) Sons Name Age
c) Unmarried daughters
d) Widow daughters
e) Parents wholly dependent on the deceased HAU
employee
f) Widowed/unmarried sisters
5. General financial condition of the family
(to be indicated in affidavit proforma A/I)
6. Any other source of income
7. In case the widow/or any member of the deceased
is employed, give detail of employment indicating
the monthly emoluments drawn in each case.
8. Any other relevant information
Place :
Date : Signature of applicant
18
ASSISTANCE OUT OF EX-GRATIA GRANT
AFFIDAVIT
I, _____________________ W/o /S/o _____________ R/o _____________________
solemnly affirm and declare as under :-
That the following property was with my husband/father and with the members
of his family at the time of death.
(a) Detail of deposit in bank/post office.
(b) Amount of General Life Insurance & income on other investments.
(c) Detail of cash/jewellery.
(d) Details of movable/immovable property and other investments.
(e) If any amount is received from ex-gratia policy, details of the same.
2. Family members who are in Government/University service
(Income in each case be mentioned)
Sr.
No.
Name of member and
relationship with
deceased
Age Whether
married or
unmarried
Detail of job
& monthly
income
1.
2.
3.
4.
5.
3. The following are the sources of income of family members :-
(a)
(b)
(c)
4. I was fully dependent on the deceased/University employee.
DEPONENT
VERIFICATION
I further hereby declare that the information given in the application form under
the ex-gratia scheme and in the affidavit is correct and true to the best of my
knowledge and belief and nothing has been concealed therein.
DEPONENT
19
PART-B
(To be filled by the Head of office/department)
1. Name of the deceased employee
2. Circumstances under which the employee
died
3. Length of service
4. Date of birth
5. Details of monthly emoluments drawn at
the time of death (with pay scale)
6. Financial conditions of the family
alongwith exceptional features, if any.
7. Record of service alongwith exceptional
features, if any
8. Property owned by the deceased employee
(copy of property declaration be attached)
9. Period between date of retirement and date
of death.
10. a) Benefits which would have been accrued
to the deceased by way of GPF/CPF,
gratuity, if he had retired in the normal
course.
b) Benefits which his family will not
receive as CPF/GPF/Gratuity
11. Amount of CPF/GPF at the credit of the
deceased employee at the time of death.
12. Where are the sons of the deceased settled
and what are their monthly income
13. Amount of ex-gratia grant recommended
Note : Lump-sum grant equal to 10 times the last emoluments drawn before the
employee’s death subject to a minimum Rs.10,000/- and a maximum of Rs.25,000/-
provided the record of service of the deceased is not exceedingly adverse, say in the
matter of integrity.
Place : Signature of the Head of office/deptt.
Dated :
20
PART-C
(For use of Administrative Department/Head of Deptt.)
1. Recommendations by the Head of the Department
2. Recommendations by the Controlling Officer
PART – D
Forwarded to the Comptroller for sanction and payment of ex-gratia grant as
per HAU rules.
(ii) The CR/SAR file, service book and personal file of Dr./Sh./Smt.
___________________________________ are enclosed herewith.
21
APPLICATION FOR PAYMENT OF LEAVE ENCASHMENT
1. Full information of the deceased University Employee :
(i) Name & Designation :
(ii) Deptt./office :
(iii) Date of Birth :
(iv) Date of joining of employee :
(v) Date of death (with proof) :
(vi) Pay scale :
2. Full information of Applicant/claimant
(i) Name :
(ii) Full Address :
(iii) Relationship with the deceased/ :
University employee
3. Any other information :
It is requested to release the payment of Leave Encashment as per HAU rules.
Encl : Death Certificate
Place : Signature of the applicant
Date :
22
APPLICATION FOR RELEASE OF
DEATH-CUM-RETIREMENT GRATUITY
1. Full information of the deceased University Employee :
(i) Name & Designation :
(ii) Deptt./office :
(iii) Date of Birth :
(iv) Date of joining of employee :
(v) Date of death (with proof) :
(vi) Pay scale :
2. Full information of Applicant/claimant
(i) Name :
(ii) Full Address :
(iii) Relationship with the deceased/ :
University employee
3. Any other information :
It is requested to release the Death-cum-Retirement Gratuity as per HAU rules.
Encl : Death Certificate
Place : Signature of the applicant
Date :
23
DEPARTMENT OF ____________________________
CCS HAU, HISAR
Subject : Death-cum-Retirement Gratuity (DCRG) in respect of late
Dr./Sh./Smt. ______________________________.
Dr./Sh./Smt. __________________ (designation) _________________ has
expired on ____________. Legal heir/nominee of Dr./Sh./Smt._________________
has made a request for release of Death-cum- Retirement Gratuity in respect of
him/her. He/she joined HAU service on ______________. He/she was on EOL from
___________ to _____________ (total period = _______________). He/she has thus
rendered total qualifying service in HAU for _________ years, ________ months and
_______ days. He/she has satisfactory record of service to his/her credit under Rule
6.16-A of Pb. CSR Vol.II. Death-cum-Retirement Gratuity is payable to him/her/his
family/ legal heirs as per calculations below :-
Last Basic Pay +
Grade Pay +
DA @ _______%
Total emoluments = Rs._________
Gratuity =
No Dues Certificates have been obtained from all concerned i.e. DEO,
Nehru Library, Faculty Club/Community Centre, and the Departments Funds are
available in the Department.
It is proposed that above gratuity may be recommended in favour of
Sh./Smt./Dr. __________________ and the case may be sent to the Comptroller
through Controlling Officer for according financial sanction.
Head of Department
24
CONTROLLING OFFICE
The information/particulars as furnished above has/have been checked with
reference to the service book/record is/are correct. The case is recommended to the
Comptroller for according sanction of Rs.______________ as Death-cum-Retirement-
Gratuity to the claimant - Dr./Sh./Smt.______________.
COMPTROLLER OFFICE
This is a Death-cum-Retirement gratuity case in respect of
Dr./Sh./Smt._______________ which may kindly be perused.
2. The service has already been verified in service book. No Dues Certificates
from all concerned have been obtained and entry made in the service book. The Head,
Deptt. of _______________ and _____________________ (Controlling Officer) have
recommended gratuity amounting to Rs.___________. Funds are available in the
concerned department/office. The case has been examined and found in order.
3. The gratuity has been calculated as under :-
Last Basic Pay + GP+DA ( ) X completed half years
4
4. The case is submitted for sanctioning a retirement gratuity of
Rs._______________ (Rupees _______________________________________
____________________________ only) in favour of Dr./Sh./Smt. ___________,
Department/office of ____________________________ please.
25
APPLICATION FOR COMPASSIONATE FINANCIAL ASSISTANCE
1. Full information of the deceased University Employee :
(i) Name & Designation :
(ii) Deptt./office :
(iii) Date of Birth :
(iv) Date of joining of employee :
(v) Date of death (with proof) :
(vi) Date of missing :
(vii) Pay scale :
2. Full information of Applicant/claimant
(i) Name :
(ii) Full Address :
(iii) Relationship with the deceased/ :
missing Government employee
(iv) Detailed information regarding :
Dependents of deceased/missing
Government employee
Sr.
No.
Name Relationship Age/date
of birth
Occupation Married/unmarried
1. 2. 3. 4. 5. 6.
3. Monthly income of family from all sources :
4. Any other information :
Encl : (i) Death Certificate
(ii) An undertaking on affidavit in view of employment/remarriage
Place : Signature of the applicant
Date :
26
DEPARTMENT OF ____________________________
CCS HAU, HISAR
Subject : Compassionate Financial Assistance in respect of late
Dr./Sh./Smt. ______________________________.
Dr./Sh./Smt. ___________________ (designation) _____________ has
expired on ______________. Legal heir/nominee - he/she______________ of
Dr./Sh./Smt._________________ has made a request for payment of Compassionate
Financial Assistance. The date of birth of the deceased employee is ____________ and
he/she has joined the University service on ____________. He/she was due for normal
retirement on attaining the superannuation on ___________.
2. As per Sr. No. 5(1) (b) & 5 (2) of State Govt. Notification dated 1.8.06
adopted in the University vide Endst. No. 5434-5583 dated 11.8.06 and clarification
received from the Govt. vide letter dated 18.12.07 and adopted by the University vide
Endst. No. Admn.E.3/08/1345-1494 dated 22.2.08, on the death of any employee, the
family of the employee would continue to receive as financial assistance, a sum equal
to the pay and other allowances that was last drawn by the deceased employee in the
normal course without raising a specific claim for a period of 7 years or till the date the
employee would have retired from Govt. service on attaining the age of
superannuation whichever is less, if the employee had attained the age of 48 years and
above. The family shall also be eligible to receive family pension as per normal rules
(if the deceased employee has opted pension) after the period of financial assistance is
over.
3. The detail of the last salary drawn by the deceased employee is as under :-
(i) Basic Pay
(ii) Grade Pay
(iii) NPA
(iv) Special Pay
(v) ADA
(vi) FMA (if opted) _______________
Total : _______________
4. No Dues Certificates have been obtained from all concerned i.e. DEO, Nehru
Library, Faculty Club, Community Centre, Bank (if loanee) and the departments.
Nothing is due against him. The legal heir/nominee – he/she _____________ of the
deceased employee is entitled for Compassionate Financial Assistance for a period
w.e.f. _______ to _________ @ Rs.________ p.m. (BP+GP+SP+NPA+FMA+ADA).
27
Increase in ADA from time to time will also be admissible. Thereafter, he/she will be
entitled to family pension (if the deceased employee was in pension scheme), as per
rules. It is proposed that the above case may be recommended to the Registrar through
Controlling Officer for issuing the necessary orders of Compassionate Financial
Assistance as per rules.
CONTROLLING OFFICER
The above case has been checked and is in order. So, the case of the nominee
of Late Sh./Smt./Dr.________________________ for making the payment of
Rs.___________ p.m. w.e.f.___________ to ___________ on account of financial
assistance is recommended and forwarded to the Registrar for obtaining the sanction of
the Vice-Chancellor and issuing necessary orders.
REGISTRAR OFFICE
This is a case of Compassionate Financial Assistance in respect of
Sh./Smt./Dr.________________________ which may kindly be perused.
The information furnished above is correct. In view of the same, may
submit the case to the Vice-Chancellor for approval of Compassionate Financial
Assistance of Rs.__________________ p.m.(BP+GP+ NPA+SP+ADA+FMA) w.e.f.
_______ to _________ in respect of Late Sh./Smt./Dr.___________ to
Sh./Smt.________ legal heir of the deceased family whereafter the necessary
administrative orders will be issued. The increase in ADA from time to time will also
be admissible. Thereafter, the family of the deceased employee (if pension opted) will
be entitled to the family pension as per HAU Pension Rules please.
28
To
The Comptroller,
CCS HAU, Hisar.
(Through Proper Channel)
Sub :- Final payment of CPF/GPF.
Sir,
It is requested that arrangements may kindly be made for payment of the
accumulation in the Contributory Provident Fund/General Provident Fund account No.
of Sh/Smt……………………………. . Necessary particulars required in this
connection are given below :
1. Name of University employee.
2. Date of joining .
3. Date of birth.
4. Date of death.
5. Post held by University employee at the time of death.
6. Proof of death in the form of death Certificate issued by
the Municipal Authority etc.
7. (a) GPF account No.
(b) CPF account No.
8. The amount of CPF/GPF money standing to the credit of the subscriber at the
time of his/her death is Rs…………….. as per annual statement.
9. Details of nominee(s) alive on the date of death of the subscriber (if nomination
subsists) are as under :
Name of nominee Relationship with
Subscriber
Date of birth
of Nominee
Share of the nominee
1 2 3 4
10. In case no nomination subsists the details of surviving member(s) of the family
on the date of death of the Subscriber as under:
(i) Name
(ii) Relationship with the subscriber
(iii) Date of birth
29
Note (for para 9 and 10 above)
In case of minor nominee the claim should be supported by indemnity bond or
guardianship certificate, as the case may be.
11. If the subscriber has left no family and no nomination subsists (the names of
persons to whom the CPF/GPF money is payable should be supported by letter
of probate or succession certificate etc):
(i) Name
(ii) Relationship with subscriber
(iii) Date of birth
(iv) Address
(v) Religion of the claimants
12. The following documents duly attested by the Gazetted Officer/Magistrate are
also attached.
(i) Personal marks of identification
(ii) Left/right hand thumb and finger impression
(in case of illiterate claimants).
(iii) Specimen signatures in duplicate
(in case of literate claimants).
(iv) Photograph in duplicate.
Yours faithfully,
Signature of Claimant
Place : …………………… Name :
Date : …………………… Address :
Office of ………………Deptt./office
Endst. No.
Forwarded to the Comptroller for necessary payment.
2. Certified that the claimant is the rightful nominee/ legal heir to receive the
outstanding amount of CPF/GPF Account No………… in the name of
Sh………………. for Rs……………..
3. Signatures and photographs of the claimant are duly verified.
4. The entry of death has been made in the service book on page ……….
and duly verified by the Head of Deptt.
30
5. Has the above entry been got verified from RSA under full signatures ?
6. The date of bill from which last GPF/CPF deduction was made is …………
7. Details of recoveries, if any, duly verified from Audit are as under :
8. No Dues Certificate from others concerned (i.e. Librarian, DEO, Secretary,
Faculty Club/Community Centre) are at Pages …………. of personal file.
9. It is certified that nothing is due against the subscriber except Rs……………..
as mentioned above.
10. The following documents are sent herewith :
(i) Service Book.
(ii) Personal file (Page 1……to……).
(iii) Death Certificate
(iv) Nomination
(v) Documents as mentioned under para-12 of the applicant.
Signature of HOD/Office
Deptt./Office
Date
Note : Details whatever is inapplicable.
31
Sub: Final payment of GPF/CPF
PUC is an application of Dr./Sh./Smt. ________________________________
______________________________ Ex _____________________________ office of
the _______________________________________________ received through proper
channel for the refund of Contributory Provident Fund/General Provident Fund.
2. The total amount of Rs. ________________ + Interest Rs.________________
upto ___________ is standing to his/her credit under CPF/GPF A/c
No.___________.
Orders of acceptance of resignation/termination/retirement/voluntary retirement
may kindly be perused at __________. He/she joined University service on
regular basis on _____________ and left on ___________.
3. His/her service in the University since commencement of subscription of CPF is
not/is less than three years. He/she is not entitled to get University share of CPF.
4. As per ‘No Dues Certificate from Librarian ( ). Dy. Estate Officer ( ),
Secretary, Community Centre/Faculty Club ( ) and Head of
Deptt./Office ( ) and service-book page No. ______, recovery of
Rs.____________________ is due.
5. Consent of the subscriber for effecting this recovery out of his/her CPF/GPF is
at ____________. Audit verification of recoverable amount is at
______________.
6. May refund the payment of CPF/GPF of Rs. ____________________________
(Rupees ______________________________________________________) as
per details given overleaf, please.
7. Payee’s A/c Cheque in f/o _______________________________________.
Asstt.
32
CHAUDHARY CHARAN SINGH HARYANA AGRIL. UNIVERSITY , HISAR
FAMILY PENSION
1. Name & Designation of the deceased
2. Father/Husband's name
3. Date of birth
4. Date of entry into University service
5. Date of Death
6. Nature of claim
7. Relationship with the deceased
8. Postal Address
9. Permanent Address
10. Name of the family pensioner
33
FORM PEN 18
Form of letter to Controlling Officer for forwarding papers for the grant of
family pension
From
HOD concerned,
CCS HAU, Hisar.
To
The ………………. (Controlling Officer)
CCS HAU, Hisar.
Memo No. Dated :
Sub :- Grant of Family Pension.
It is to point out that Sh. ……………………………………………………..
Designation ……………………………died on ………………………………………
His family has become eligible for the grant of family pension. Form PEN 17 duly
completed is forwarded herewith for further necessary action.
1. University dues in respect of the deceased University employee will be
recovered out of Death-cum-retirement gratuity as indicated in section II of
Part-I of form PEN 17.
2. Your attention is invited to the list of enclosures which is forwarded herewith.
Yours faithfully
Head of Office
List of enclosures :-
Sr.No. Particulars
1. PEN 17 Application form duly completed (Rules 9.12(1), 9.24(1) (3) and (5)
and 9.26 (1) and (5).
2. Service Book indicating date of death.
3. Specimen signatures/left hand thumb and finger impression of the claimant
or guardian duly attested.
4. Three copies of passport size photograph of the claimant or guardian duly
attested.
5. Two copies of descriptive roll of the claimant or guardian duly attested
indicating height and personal marks.
34
6. Postal address of the claimant or guardian.
7. Annexure-I - Form of letter from HOD concerned to the widow/ Widower of
the deceased employee for grant of family pension.
8. Annexure-II - Form of application for the grant of family Pension on the
death of the employee - also see PEN 19 & 20.
9. Annexure-III - Form for sanctioning Family Pension.
10. Calculation sheet of Family pension.
11. No Dues Certificate in respect of long term advances & other Recoveries, if
any, by HOD, Librarian, DEO, Faculty Club, Community Centre.
12. No. complaint/Enquiry Certificate.
13. L.P.C.
14. Consent of the legal heir of the deceased University employee to recover the
amount of advances, if any, alongwith interest taken out of University share
of CPF alongwith interest taken out of own share of the employee and if
there is still any short-fall, the consent to recover the balance out of other
retiral benefits, if he/she opts for family pension.
15. Statement indicating reason for delay for not forwarding Application within
prescribed time, as per PCSR Vol. II Rules.
16. Employment/Non-employment Certificate from spouse claiming Family
pension.
17. Certificate of correctness of particulars/calculations by A&AO of the
Controlling Officer.
Endst. No. Dated :
Forwarded herewith the pension papers in respect of ……………….of the
Deptt. of ……………..…….. to the Comptroller, CCS HAU, Hisar. It is certified that
the particulars furnished in the application and its enclosures including Commutation
application are in order. Further necessary action to release the P.P.O. may be taken at
his end.
Signature
(Designation of Controlling Officer)
35
(FORM PEN 17) See rules 9.22(1), 9.24(1), (3) and (5) and 9.26 (1) and (5)
FORM FOR ASSESSING AND AUTHORISING THE PAYMENT OF FAMILY
PENSION WHEN A UNIVERSITY EMPLOYEE DIES WHILE IN SERVICE
To be sent in duplicate.
PART I
SECTION I
1. Name of the deceased University employee.
2. Father's name and also husband's name in
the case of female Univ. employee.
3. Date of birth (by Christian era).
4. Date of death (by Christian era).
5. Religion and Nationality.
6. Office/department in which last employed.
7. Appointment held last
(1) Substantive (2) Officiating
8. Date of beginning of service
9. Date of ending of service.
10 (i) Total period of military service for which pension/gratuity was sanctioned; and
(ii) Amount and nature of any pension/gratuity received for military service
11. Amount and nature of any pension received for previous civil service, if any.
12. Deptt./office under which service has been rendered in order of employment.
13. The date on which intimation regarding the death of a Univ. employee was
received by the Head of office.
14. The date on which action initiated to :
(i) Obtain claim or claims from the
Claimants in the appropriate form
death -cum-retirement gratuity and family
Pension as provided in rule 9.21.
(ii) Obtain the "No Dues certificate" from
the HOD, DEO, Library, F.Club, Community Centre.
(iii) Assess the Univ. dues other than the
dues pertaining to occupation of Univ.
36
Accommodation as provided in rule
9.24(2).
(iv) Assess the service and emoluments
qualifying for death-cum-retirement
Gratuity and family pension as provided
in rules 9.22 and 9.23.
15. Whether nomination made for Death-cum-
Retirement gratuity.
16. Length of service qualifying for Death-cum-
Retirement gratuity/pension.
17. Period of non-qualifying service.
(i) Interruption in service condoned under rule 3.17A.
(ii) Extra-ordinary leave not qualifying for Gratuity.
(iii) Period of suspension treated as non-qualifying
From……………….. to ………………….
(iv) Any other service not treated as qualifying Service.
Total period of non-qualifying service.
18. (a) Emoluments reckoning for Death-cum Retirement gratuity.
(b) Amount of Death-cum-Retirement Gratuity.
19. If Family Pension Scheme 1964 applies.
(i) Proposed family pension at :
(a) Enhanced rates (if service rendered at the time of death is more
than seven years) as in para 2 of Appendix I to these Rules )
(b) Ordinary rates (as in para 1 of Appendix 1 to these rules).
(ii) Period of tenability of Family Pension Scheme, 1964.
(a) Enhanced rates From To
(b) Ordinary rates
20. Person to whom family pension is payable.
Name : (Relationship with the deceased University employee)
Full postal address
37
21. Details of University dues recoverable out of gratuity:
(i) Licence fee for occupation of Univ. accommodation (see rule 9.27)
(ii) Amount of Death-cum-Retirement Gratuity to be held over pending
receipt of information from the D.E.O.
(iii) Dues referred to in rule 9.27(2).
22. Date on which claim received from the Claimant(s).
23. Name of guardian who will receive payment of Death-cum-Retirement
Gratuity and family pension in the case of minors.
24. Place of payment(branch of public sector Bank)
25. Head of Account to which family pension is debitable
Place
Dated the Signature of Head of Office
--------------------------------------------------------------------------------------------------------
38
SECTION II
Details of provisional family pension and gratuity to be sanctioned by the
pension sanctioning authority in accordance with rule 9.25.
Provisional family pension Rs. ……………………………………..
Gratuity (the amount mentioned in Item
18(b) of Part-I)
Rs. ...…………………………………...
Less
(a) Licence fee recoverable from
Gratuity for occupation of
University accommodation (as in
item 21(i) of part-I)
Rs. ……………………………………
(b) Amount of gratuity to be held over
pending receipt of information from
the DEO as item 21(ii) of part-I)
Rs……………………….…………..
(c) Other University dues as mentioned
in item 21(iii) of part-I
Rs………………………………………
(d) Other University dues as mentioned
in item 21(iii) of part -I
Rs……………………………………..
Place :
Dated, the Signature of Head of Office
39
SPECIMEN SIGNATURES
Specimen Signatures of Sh./Smt. ………………..…………………….…….
Designation ……………………….……………………………… Attested
1. ……………………………….
2. ……………………………….
3. ……………………………….
(Signature)
Designation with stamp
--------------------------------------------------------------------------------------------------------
PARTICULARS OF HEIGHT IDENTIFICATION MARKS
Sh./Smt………………………………….……….Designation…………..…………….
Particulars of Height …………………………..
Personal Marks of Identification ……………………………………………..…………
Attested ……………………………
(Signature)
Designation with stamp
Sh./Smt……………………………………….……….Designation…………..………
……. Particulars of Height …………………………..
Personal Marks of Identification ……………………………………………..…………
Attested ……………………………
(Signature)
Designation with stamp
40
FORM OF LETTER TO THE WIDOW/WIDOWER OF A DECEASED
UNIVERSITY EMPLOYEE FOR THE GRANT OF A FAMILY PENSION
No…………………………..
Deptt./office of …………….
Dated, the :
To
…………………………..
………………………….
………………………….
Sub :- Payment of Family Pension Scheme, 1964 in respect of Late
Sh./Smt……………………….
Sir/Madam,
I am directed to say that in terms of Appendix I of Punjab Civil Services
Rules, Volume-II, a family pension is payable to you as widow/widower of late
Sh./Smt. ………………………..……………… (Designation in the office/Department
of ……………………………….).
1 You are advised that a claim for the grant of family pension may be submitted
in the enclosed Annexure-II.
2 The family pension will be payable till your death or re-marriage, whichever
event occurs earlier. In the event of your death or re-marriage the family pension shall
be granted to the child or children, if any, through the guardian.
Yours faithfully,
(Head of Office)
--------------------------------------------------------------------------------------------------------
Attestation should be done by two Gazetted University employees or two or more
persons of respectability in the town, village or pargana in which the applicant resides.
41
Attested Photograph
of the applicant
ANNEXURE-II
FORM OF APPLICATION FOR THE GRANT OF FAMILY PENSION ON
THE DEATH OF THE UNIVERSITY EMPLOYEE/PENSIONER
1. Name of the applicant
(i) Widow/widower
(ii) Guardian, if the deceased person is survived by
child or children
2. Name and age of surviving widow/ widower and
children of the deceased university
employee/pensioner.
S.
No.
Name Relationship
with the
deceased person
Date of birth by Christian
era (to be attested by Head
of Office)
1.
2.
3.
4.
5.
3. Date of death of the Univ. employee/
pensioner
4. Office/Deptt. in which the deceased Univ.
Employee/pensioner served last.
5. If the applicant is guardian, his date of birth
and relationship with the deceased Univ.
employee/pensioner.
6.A If the applicant is a widow/widower the
amount of service pension which she/he may
be in receipt on the date of death of the
husband/wife.
6. Full address of the applicant :
7. Place of payment of pension and gratuity
(Public Sector Bank Branch)
8. Enclosures :
42
(i) Two specimen signatures of the applicant, duly attested (To be furnished
in two separate sheets).
(ii) Two copies of passport size photograph of the applicant, duly attested.
(iii) Two slips each bearing left hand thumb and finger impressions of the
applicant, duly attested.
(iv) Descriptive Roll of the applicant, duly attested, indicating (a) height and
(b) personal marks, if any, on the hand, face etc. (To be furnished in
duplicate).
(v) Certificate(s) of age (in original with two attested copies) showing the
dates of birth of the children. The certificate should be from the
Municipal Authorities or from the Local Panchayat or from the Head of
a recognized school if the child is studying in such school (This
information should be furnished in respect of such child or children the
particulars of whose date of birth are not available with the Head of
Office).
(vi) Death Certificate.
9. Signature of left-hand thumb impression of the applicant.
10. Attested by :
Name Full Address Signature
_____________________________________________________________________
11. Witnesses :
(i) …………………………………………………………………………….
(ii) ……………………………………………………………………………
Note : Attestation should be done by two gazetted Univ. employees or two or more
persons of respectability in the town village or Paragana in which the applicant
resides. To be furnished in case the applicant is not literate enough to sign his
name.
In the case of re-marriage of the widow while applying the family pension on
behalf of the minor child, the widow should furnish (i) the date of her re-marriage, (ii)
Name of the public sector Bank branch at which payment is desired and (iii) her full
address in the application for family pension. It is not necessary to furnish a fresh
application nor the documents as they are already available with the pension papers on
which family pension was originally admitted to her.
43
ANNEXURE-III
FORM FOR SACNTIONING FAMILY PENSION
1. Name of the University employee
2. Father's name and also husband's name in the case of
woman (Univ. employee)
3. Relationship and Nationality
4. Last appointment held including name of establishment
5. Date of beginning of service
6. Date of ending service.
7. Substantive appointment held
8. Pension Rules opted/eligible
9. Length of continuous qualifying service prior to death
10. Pay as per paragraph 2 of the Punjab Govt. Finance
Deptt.'s letter No.7856 (7) FRI/64/9691 dated the 16th
October, 1964 Annexure 1 to Punjab CSR Vol.II 1969
Edition as applicable to Haryana State).
11. Amount of family pension admissible
12. Date from which pension is to commence
13. Place of payment (Branch of public sector Bank)
The undersigned having satisfied himself of the above particulars of late
Shri/Smt………………………………………….… hereby orders the grant of family
pension of Rs……………………. p.m. to Sh./Smt. ……………………………………
which may be accepted by the Comptroller, CCSHAU, Hisar as admissible under the
rules.
Signature and Designation
of the sanctioning authority
44
CALCULATION SHEETS OF FAMILY PENSION/DCRG
1. Name & Designation ………………………………
2. Date of birth ………………………………
3. Date of joining service ..……………………………..
4. Date of death ...…………………………….
5. Gross service ………………………………
6. Less non-qualifying service ………………………………
7. Net qualifying service ………………………………
(In term of six monthly period)
8. Pay including S.P. or P.P. on the date of death ………………………………
9. Normal family pension admissible ...…………………………….
10. Enhanced rate of Family pension ................……………………
11. Amount of D.C. R.G. ..…………………………….
Last pay drawn X multiply by six
Monthly Period (limited to 66/70)
45
NO DUES CERTIFICATE
Certified that there is no long term advances and other advances outstanding :
pending against Sh./Smt. ………………………………..……………………………..
Designation ……………………………..…….…………………………………………
Date of death ………………………………...………………………………… ……….
Date of Birth ……………………………………………….……………………………
(Signature of Head of Office)
_____________________________________________________________________
NO COMPLAINT/ENQUIRY CERTIFICATE
Certified that there is no complaint/Enquiry pending
against Sh./Smt. ………………………………………………………………………
Designation ………………………………………………………………………
Date of death ……………………………………………………………………..
_____________________________________________________________________
(Signature of Head of office)
1 In case any complaint/Enquiry pending against the applicant detail thereof.
2 In case he was suspended any time, brief statement leading to reinstatement
after having been either suspended, compulsorily retired, removed or
dismissed from service.
(Signature of Head of office)
46
Office of the ……………………………………………………………………………..
No. ………………………………………………………………………………………
office case ….……………………………………………………………………………
Provincial LAST PAY CERTIFICATE OF Mr./Mrs. …………….………………… ..
of the ……………………………………………………………………………..… …..
proceeding……………………….………….… RETIREMENT (Nature of retirement).
w.e.f………………………………. .
2. He has been paid upto …………………………………………………… at the
following rates :
Particulars Amount (in Rs.)
1 Pay
2 SP/PP
3 DA/ADA
4 HRA
5 CCA
6 FIXED MEDICAL ALLOWANCE
7 CONVEYANCE ALLOWANCE/
MEDICAL REIMBURSEMENT
8. DEDUCTIONS
1 GPF/CPF Monthly Subscription
2 GPF/CPF Advance
3 HRA
4 Car/Scooter Advance
5 G.I.S.
6 E.W.F.
7 House Rent dues
8 PLI
9 Any other deduction
3. He has made over charge of the office of ……………………………… on the
…………………………….. Noon of the ………………………
4. Recoveries are to be made from the pay of the University employee as detailed
on the reverse.
47
5. He has been paid leave salary as detailed below. Deductions have been made as
noted on the reverse.
Period…………….…….rate………………amount…………from………..to…………
at……………… Rs……………. A month.
Head of office/deptt.
DETAILS OF RECOVERIES
Name of recovery ……………………………………………
Amount : Rupees ……………………………………………
To be received in ……………………… instalments.
SALARY DEDUCTIONS MADE FROM LEAVE SALARY
From ……………. To ……………………. On account of ………………………
From ……………. To ……………………. On account of ………………………
From ……………. To ……………………. On account of ………………………
Head of Office/Deptt.
Signature with Stamp
Name of Pay Gratuity Fee Funds and other Amount of Income-tax Remarks
Months Deductions recovered
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Jan.
Feb.
March
He took over/assumed charge of the office of …………………..………………. on the
………………………………………………….. noon of ……………………………..
Signature Designation
48
CERTIFICATE REGARDING EMPLOYMENT
Certified that I, …………………………..………………………. Widow/widower of
Late Sh./Smt. …………………………………………. , am not in employment of any
Govt. or any other organization.
(Signature of claimant)
…………………………………………………………………………………………
CERTIFICATE
It is certified that the particulars/calculations filled up in the application form
and its enclosures of Sh. ………………………… Designation ………………………
Department/Office of ………………………………….. have been duly verified and
found correct.
Controlling Officer
49
D
M
Net qualifying
service
Y
6
Reasons for
non-
qualifying
service
5
D
M
Less -
Non-qualifying
service
Y
4
D
M
Total period
Y
3
Period from
------------------
------------------
2
Sr. No. Page No. of
Service Verification
Certificate as per
service Book
1
Signature Head of Office/Deptt.
DETAILS OF QUALIFYING SERVICE
(as defined to in Col. 15 of Form Pen 1)
To be filled up department-wise/designation-wise where the official worked from time to time)
50
FORM OF CERTIFICATE OF VERIFICATION OF SERVICE FOR PENSION
(as given in FORM PI 15)
CERTIFICATE
It is certified that Sh./Smt. …………………………………… has completed a
qualifying service of ………………years………….. months and ………. days which
has been verified on the basis of his service documents and in accordance with the
rules regarding qualifying service in force at present. The verification done under sub-
rules (1) and (2), of rule 5.34-A shall be treated as final and shall not be re-opened
except when necessitated by a subsequent change in the rules and orders governing the
conditions under which the service qualifies for pension.
Signature Head of Office/Deptt.
51
Period of qualifying service are as under : -
(i) Period and details of earlier/past services other than HAU proposed to
be counted after obtaining information from previous employer as per
statutory provisions.
(ii) Amount and nature of pension/gratuity or any other terminal benefits
received for service of the above period.
(iii) Period of war/military service.
(iv) Amount and nature of pension/gratuity and other terminal benefits
received for above service.
(v) Details of break in service, if any.
(vi) Details of extra-ordinary leave or any other non-qualifying service not
counted for pension.
(vii) Details of service on deputation/foreign service.
(viii) Certified that the leave salary and pension contributions of the above
service have been received by the University and deposited in University
account and the entries thereof have been made in the Service Book.
Signature of Head of Office/Dept
52
DESCRIPTIVE ROLL
Submitted by the ____________________________
1. Name and residence showing
Village, Tehsil and District
_______________________________
Description of the claimant
2. Age _______________________________
3. Height _______________________________
4. Race, caste or tribe _______________________________
5. Marks for identification _______________________________
6. Present occupation and pecuniary
circumstances
_______________________________
7. Degree of relationship to deceased. _______________________________
Description of the deceased
8. Name _______________________________
9. Occupation _______________________________
10. Income of the deceased _______________________________
11. Nature of injury causing death _______________________________
Signature of the Applicant