COMBINED APPLICATION FORM FOR GENERAL PROVIDENT FUND FINAL CLOSURE AND PENSION

PART I

FOR RETIREMENT / REVISION CASES ONLY

(To be sent in Duplicate)

1. Name of the Government Employee : Mr.M.CHINNASAMY

(IN CAPITAL LETTERS)

2. Husband’s Name in the case of Female : Mrs. TOTHI

3. Designation with Selection Grade / : Sanitary worker

Special Grade GOVT. RAJAJI TB HOSPITAL,

TRICHIRAPPALLI.

4. Religion : INDIAN-HINDU

5. P.P.O. No. allotted by A.G’s Office

(Applicable only for Revision Cases) : NEW PENSION PROPOSALS

6. G.P.F. No. with Departmental Suffix 116919/MEDL

7. Date of birth 8. Date of Joining 9. Date of Retirement

11.05.1959 07.11.1990 FN 31.05.2019 A.N

10. Present Residential Address with PIN Code : NO. 36/18, New colony
Mannachanallur
Trichy-621 005.
MOBILE No. 9786695855

11 .Residential Address after Retirement : NO. 36/18, New colony ,

Mannachanallur
Trichy-621 005.

MOBILE No. : 9786695855

12. Place of Payment of Pension
(a) Pension Pay Office
(b) District Treasury : DISTRICT TREASURY – TRICHY
(c) Sub-Treasury :

13. Whether the Pension is proposed

to be commuted (Tick in appropriate Place)? : Yes :

If Yes, fraction proposed to be commuted : Fraction: 1/3 of

: Pension=Rs. 4931/-
14. Are you in receipt of Military Pension? : NO

15. If Yes, P.P.O. No. and Treasury from

which it is drawn may be furnished : NO

16. If you are in receipt of Military Pension,

state whether you opt for Military

Family Pension or Civil Family Pension

(Option once exercised is final) : NIL

17. List of Family Members including Wife/Husband:

Whether
Handicapp
Sl.
Name(s) Relationship Marital Status Date of Birth ed/
No.
Mentally
Retarded*

1. C.JOTHI WIFE MARRIED 26.11.1974

NO

C.CHARU NISHA DAUGHTER AN MARRIED 16.06.2001 NO

2.

*Medical certificate to be enclosed.

18. Name of Guardian in case of

mentally retarded children : DOES NOT ARISE
DECLARATIONS
I hereby declare that I have neither applied for nor received any Pension or
Gratuity in respect of any portion of the service qualifying for this pension and in respect
of which pension and Gratuity are claimed herein not shall I submit an application
thereafter without quoting a reference to this application and the orders which may be
passed thereon.

I do hereby declare to refund the pension or gratuity authorized by the

Accountant General, Chennai, if afterwards found to be in excess of the amount to which I
am entitled under the Rules.

I hereby certify to make good any loss caused to the Government by way of
any overdraw of pay, allowances, leave salary or other admitted obvious dues as a result
of negligence or fraud on my part in service in the department in a lump sum or in
suitable installments from my pension.

Place: TRICHIRAPPALLI Signature of Government

Date: Employee with Date

 PART II

TO BE FILLED IN BY THE DEPARTMENTAL OFFICER

1. A.G’s Office Reference No. in which the :: NEW PENSION

proposals were returned with objections PROPOSALS
earlier

2. Date of Beginning of Service :: 07.11.1990 F.N.

3. Date of Ending of Service :: 31.05.2019A.N.

4. Gross Qualifying Service :: Y M D

28 06 24

5. Non- Qualifying service (1.6.85 00 01 23

to 23.9.85 - 3Months and 23Days)

6. Additional Qualifying Service under Rule :: NIL

27 / Due to Voluntary Retirement /
Contingent Service / Military Service

7. Net Qualifying Service :: Y M D

28 05 01

8. Total Period of Military Service and :: NIL

Military Pension / Gratuity received
(Details of remittance to be furnished
separately)

9. Scale of Pay : Rs.16600– 52400 LEVEL 03

CELL-23

10.Pay Last Drawn (Special Pay, Personal Pay

drawn if any to be shown separately) : Rs.31700

11. Class of Pension applicable : SUPERANNUATION

12. Whether any charges are pending against

the Government Employee? If so, furnish
the details thereof : NIL
13. Office served in the last three years :

Name of the Office From To

SUPERINTENDENT , 01.11.2009 TILL DATE

Govt. TB Hospital
TRICHIRAPPALLI
 14. a) Drawing Officer for G.P.F. with
Full Postal Address and PIN Code
b) Phone No. of the Office with STD Code
c) e-mail ID / FAX
: JUNIOR ADMINISTRATIVE OFFICER
GOVT.RAJAJI TB HOSPITAL ,
TRICHIRAPPALLI -620 001..
: 0431 2460623
: 0431-

15. Treasury / PAO for G.P.F. : DISTRICT TREASURY

TRICHIRAPPALLI

16. a) Drawing Officer for D.C.R.G. with : JUNIOR ADMINISTRATIVE OFFICER

Full Postal Address and PIN Code GOVT.RAJAJI TB HOSPITAL ,
TRICHIRAPPALLI -620 001.
b) Phone No. of the Office with STD Code : 0431 -2460623
c) e-mail ID / FAX : 0431-

17. Treasury / PAO for D.C.R.G : DISTRICT TREASURY, TRICHY

18. Particulars of Last G.P.F. Deduction (Last 10 Months Details):

GPF
Pay for Recovery/ Date & Place of Sub-A/C of Voucher
Subscrip- Total
Month tion Refund Payment Account No.
(1) (2) (3) (4) (5) (6) (7)

January19 4500 9000 13500 District Treasury SA16

Trichy

Febr-19 4500 9000 13500 District Treasury SA16 -

Trichy
19. Details of T.A./Part Final Withdrawal sanctioned in the last 12 Months

90% PART FINAL WITHDRAWAL

Month Amount Voucher No. Date of Payment

(1) (2) (3) (4)

November 18 216000- Nil 23.11.2018

CERTIFIATE

It is certified that

1. All the particulars furnished above have been fully verified with reference
to Office records and are found correct.
2. Advance / Withdrawal from GPF was granted during the last 12 months as
detailed in Column 18 above.
3. No charges are pending / against the individual.
4. Provisional Pension not paid/ Provisional Pension paid.
5. Conditions laid down in Rule 11(2) and Rule 11(3) of the Tamil Nadu
Pension Rules,1978 have been satisfied and the same has been recorded in
Service Book.

Signature of the Head of Office

SUPERINTENDENT
GOVT.RAJAJI TB HOSPITAL,
TRICHIRAPPALLI
 CHECK LIST / LIST OF ENCLOSURES

1. Service Book(s) [No. of Volumes] : ENCLOSED

2. Recent Joint Passport size Photo with
Spouse. Specimen Signature / left hand
thumb impression (in the case of
illiterate) and Descriptive Roll of the
Government Employee, all in triplicate,
duly attested [furnished in the Annexure] : ENCLOSED
3. Sanction order in respect of Non-Government
Aided Educational Institution cases and
Missing Employee : DOES NOT ARISE
4. In case of Teachers, Non-Employment/
Re-employment Certificate : DOES NOT ARISE
5. Copy of First Information Report in
Respect of Missing Employee : DOES NOT ARISE
6. Nomination for General Provident Fund : ENCLOSED
(GPF)
7. Nomination for Death cum Retirement
Gratuity (DCRG) : ENCLOSED
8. Nomination for Life Time Arrears of Pension : ENCLOSED
9. Nomination for Commutation of Pension
(in duplicate) : ENCLOSED
10. Medical Certificate in original in Form 23
as prescribed in Rule 36 of TNPR for
invalidation cases issued by Medical Board : DOES NOT ARISE
11. Certificate of Medical Opinion of the
Doctors for admitting Commuted value
of Pension in the cases of Invalidation and
Compulsory Retirement cases : DOES NOT ARISE
12. Ratification Order of Government for
waiving any shortfall in notice period due
to sanction of EOL with MC /without Medical certificate (in respect of
Voluntary Retirement cases) : DOES NOT ARISE
13. Military Verification Certificate : DOES NOT ARISE
14. Copy of the Chalan for refund of Gratuity
received with Interest for Military Service : DOES NOT ARISE
15. Copy of Proceedings issued in the case
of Compulsory Retirement / Voluntary
Retirement / Invalidation cases : DOES NOT ARISE
16. Copy of Government Order imposing cut
in Pension issued on completion of
Disciplinary Proceedings / Dropping the
Charges. : DOES NOT ARISE
17. Copy of Adoption Deed, in case of
Adopted children : DOES NOT ARISE
18. Copy of Medical Certificate in the case of
Mentally Retarded Children / Handicapped
Children : DOES NOT ARISE

PLACE: TRICHIRAPPALLI Signature of the Head of Office /

DATE: Department with seal

INSTRUCTIONS
1. Please send the application in Duplicate/Triplicate.
2. Please fill up all columns in capital letters.
3. Incomplete application will not be processed.
4. Annual Account Statement of GPF need not be sent.
5. Last Fund deduction particulars mean deduction to GPF Before
stopping recovery.
6. For arriving at the Commuted Value of Pension, dated Signature
of the Government Servant in Part I is compulsory.
 ANNEXURE

(To be sent in Triplicate)

1. Joint Passport size Photo of the

Government Employee with spouse.

Name of Government Employee : M.CHINNASAMY - Self

Name of the Spouse : C.JOTHI- WIFE

Signature of the Head of Office

SUPERINTENDENT
GOVT.RAJAJI TB HOSPITAL,
TRICHIRAPPALLI

2. Specimen Signature of the Government Employee

1)

2)

3)

HEIGHT : 150cm

3. Descriptive Roll of Government Employee (Personal Marks of identification)

1) An old Scar in the Right knee

2) A Black mole on left knee.

SUPERINTENDENT
GOVT.RAJAJI TB HOSPITAL,
TRICHIRAPPALLI
 FORM No.26
PENSION CALCULATION SHEET

Name : M.CHINNASAMY
Designation SANITARY WORKER

GOVT.Rajaji TB Hospital, Trichirapplli

Date of Birth : 11.05.1959

Date of Entry into Government Service : 07.11.1990 F.N.

Date of Retirement : 31.05.2019 A.N.

GROSS QUALIFYING SERVICE YY MM DD

Date of Retirement 2019 05 31

Date of Entry into Govt. Service 1990 11 07

Gross Qualifying Service 28 06 24
LESS: Non Qualifying Service 00 01 23

Net Qualifying Service 28 05 01

PENSION: X Qualifying
8. Average Service [In 31700/ 2 X 57/60 =
Emoluments/2 completed 6 Rs.15058/-
monthly period
not exceeding
60] / 60
9 GRATUITY Rs.31700 =Rs.31700
1. Emoluments for gratuity DA( 9 %) =Rs. 28,53
------------------
Rs.34553
------------------

2. Retirement gratuity admissible: Calculation to be shown as

follows:
Emoluments / 4 X Qualifying Service
[In completed 6 Rs.34553 / 4 X 57=
monthly period Rs.4,92,380/-
not exceeding 66]
10. FAMILY PENSION: Rs. 15058/-
1. Emoluments for Family Pension
2. Family Pension admissible Enhanced Family
Pension at Rs.14793-
from 01.6.19 upto 7
years and thereafter
Normal Family Pension
at Rs.9510/-
 A Ordinary Family Pension Pay last X Prescribed %
drawn Subject to
Prescribed
Rs. 31700/- X 30% minimum
= Rs.9510 and
maximum

B Enhanced Family Pension: Rs.31700/- X50% =

Family Pension equal to 50% Rs.15058/-
of the pay last drawn or at
ordinary rate Subject to
Prescribed minimum and
maximum as per Rule 49.
11 COMMUTATION: Rs.15058/3=Rs.5019/-
Commuted value of Pension
Less CVP 1/3rd
Reduced Pension Rs.10039/-

Commuted Value. 5019X 8.194 X 12 = Rs.493508/-

ABSTRACT

PENSION :: Rs. 15058/-

GRATUITY :: Rs.483742/-

(R)

Rs.492380/-

COMMUTED VALUE :: Rs.493508/-

ENHANCED FAMILY PENSION :: Rs.15058/-

(1.6.19upto 7 years
from the date of
retirement or Death

ORDINARY FAMILY PENSION :: Rs.9510/-

(From 11.05.2024)

SUPERINTENDENT
GOVT.RAJAJI TB HOSPITAL,
TRICHIRAPPALLI
 ANNEXURE

TAMILNADU PENSION RULES 1978

FORM-5

(Particulars to be obtained by the Head of Office from Retiring Government

Servant one year before the date of his/her retirement)

PART-A

1. Name : M.CHINNASAMY
2. a) Date of Birth : 11.05.1959
b)Date of Retirement on : 31.05.2019 A.N.
c)Designation at the time of Retired : Sanitory WORKER
Govt.Rajaji TB Hospital,
Tiruchirappalli.
3. Two specimen signatures duly : Vide enclosed
attested (To be furnished in a
Separate Sheet)
4. Three Copies of the passport size : Vide enclosed
Joint Photograph with wife or
husband (To be attested by the
Head of Office)
5. Two slips showing particulars of : Vide enclosed
height and personal identification
marks duly attested
6. Present Address : No.36/18 New Colony
Mannachanallur
Trichy-621 005.
7. Address after Retirement : Same address
8. Name of the Treasury : Pension - D T,Trichy
: DCRG - DT, Trichy.
9. Details of the family in Form -3 : Vide enclosed
10. Class of Pension : Superannuation Pension
11. Amount of Pension authorized :Rs. 15058/-
12. Whether Pension is proposed to be : Yes.1/3 of Pension
commuted Rs. 15058x1/3=5019/-p.m
13. If so, Fraction of Pension to be : 5019x8.194x12=493508/-
commuted
Place : Tiuchirappalli.

Date :
 PART-II

1. Forwarded to the Accountant General of Tamil Nadu with the remarks that :

I. The particulars furnished by the applicant in Part I have

been verified and are correct.
II. The applicant is eligible to get a fraction of his/her
Pension amount without Medical Examination.
III. The commuted value of Pension determined with
reference to the Table
applicable at present come to Rs.492380/-(four Lakhs
ninety two thousand three hundred and eighty only.)
IV. The amount of residuary pension after commutation will
be
Rs.15058-5019=10039/-(Ten Thousand and thirty nine
only.)

2. It is requested that further action to authorize the payment of amount commuted value

of Pension may be taken as in Rules 15 of the Tamil Nadu Commutation of Pension

Rules.

3. The Commuted value of Pension is debit able under the Head of A/c.

“2071-Pension and other Retirement Benefits.”

Place: Tiruchirappalli.
Date :
SUPERINTENDENT
GOVT.RAJAJI TB HOSPITAL,
TRICHIRAPPALLI
 GPF Balance Working sheet of M.CHINNASAMY SANITARY
WORKERGovt. Rajaji TB Hospital, Tiruchirappalli is due to Retire on
Superannuation on the A.N. of 31.05.2019.

A/c.No.116919/MEDL

Balance Working Sheet

Account slip 2017-2018 Rs.145769-
As per Latest A/c Slip 4/2018 Upto DEC’18 Rs.135000/-
PCA-I Rs. NIL/-
TOTAL Rs.280769/-
Add: GPF Sub & Ref for 1/2019 to 2/2019 Rs. 27000/-
TOTAL Rs.307769/-
Withdrawal for 90% PFW Rs.216000-
(DOE on Nov 23.11. .2018)
Balance Rs.91769/-

SUPERINTENDENT
GOVT.RAJAJI TB HOSPITAL,
TRICHIRAPPALLI