APPLICATION FOR PENSION AND DEATH- CUM - RETIREMNET GRATUTITY
1. Name
2. Father’s Name and Husband name’s
3. Religion and Nationality
4. Present Address
5. Present Appointment including
The name of the Establishment
6. Date of beginning of service
7. Date of Retirement
8. Total period of Military Service
9. Length of service with details
of Interruptions
Total Service
Dis- Qualifying Service
Net Qualifying Service
10. Class of Pension and Gratuity applied
For and cause of application
11.Emoluments reckoned for Pension
12.Pension Proposed
13.Proposed Gratuity
Rs.40278.00
14.Date from which Pension is to
Commence
15.Place of Payment
16.Place of Payment
: THIRU S. GOVINDARAJU
: THIRU SENNKRISHNA NAIDU
: INDIAN - HINDU
: SANTHAMANAICKENPALAYAM
DASANAICKEN PALAYAM (PO)
POLLACHI TALUK-COIMBATORE DIST
PIN: 642 202
: VILLAGE ADMINISTRATIVE OFFICER
KANNAMPALAYAM, PALLADAM TALUK
COIMBATORE DIST
: 21.08.1995
: 31.07.2002
: Nil
: Y.. M.. D..
: 6.11.10
: Nil
: 6.11.10
: SUPERANNUATION & D.C.R.G
: Pay : Rs.3795 + PP.Rs.173
: Rs.1275.00 (vide G.O. Ms.No.678, Revenue
(ser.8 (2))
Department dated: 16.11.2007
: Rs.20139.00 and Service Gratuity
already authorised vide A.G’s Ref. No.
PEN.I /III /G.107/2115/2002-2003 dt: 17.2.2003
: 1.8.2002
: For Pension:
Sub Treasury, Coimbatore South.
: For D.C.R.G (As in col.13 - already authorized
by the Accountant General)
Signature of the Applicant
 Page 2/8

17.Pension Rules Applicable : TAMIL NADU LIBERALISED

PENSION RULES. 1978

18.Whether Nominations made : Yes

for family Pensions

19.– do-- for D.C.R.G : Yes

20.Height : 5’6”
21. Personal Identification marks
1. A black mole on the right hand elbow joint
2. A scar on the right side of the for head

1. Date on which the applicant : 31.3.2009

applied for Pension

2. Charges if any pending : Nil

3. G.P.F Account No : Nil

SIGNATURE OF THE APPLICANT

Page 3/8
 HISTORY OF SERVICE OF THIRU.S.GOVINDARAJU, VILLAGE ADMINISTRATIVE
OFFICER, KANNAMPALAYAM, COIMBATORE DIST

______________________________________________________________________________
______________________________________________________________________________
Establishment Appointment Pay DA DATE OF
REVENUE VILLAGE ADM.OFFICER Rs. Rs. Beginning Ending of
of Service
Rs.3968 Rs.1476 service
21.8.1995 31.7.2002
______________________________________________________________________________
1. Period Reckoned as Service Y.M.D
06.11.10
2. Period not Reckoned as Service Nil
3. Net qualifying Service 06.11.10 (with reference to pay
Bills and acquittances this was
very fied)
Remarks of the Receiving Authority:
1. As to the past character and conduct of the applicant Good
2. Explanation of any suspension or degradation Nil
3. Regarding Pension / Gratuity already received As stated in Col.13- already
Authorized by the Accountant
General, Chennai
1. DRG: Rs.20139.00
2. SG Rs.40278.00
1. Any other remarks Nil
2. Specific Opinion of the Receiving Authority whether
The service claimed is established and should be admitted
On or Service established may be
Admitted.

Signature of the Receiving

Authority / Head of Office

Page 4 /8
SPEIMENS SIGNATURE OF THIRU S.GOVINDARAJU, VILLAGE
ADMINISTRATIV E OFFICER, KANNAMPALAYAM, COIMBATORE SOUTH
_______________________________________________________________________
_______________________________________________________________________
__

1.

2.

3.

/Attested /

JOINT PHOTOGRAPH OF THIRU S.GOVINDARAJU AND HIS WIFE

TMT.G.PARIJATHAM
_______________________________________________________________________
_

/Attested /

Page 5/8
PARICULARS OF HEIGHT AND PERSONAL IDENTIFICATION OF MARKS
1. Date of Birth : 10.07.1944
2. Height : 5’.6”
3. Identification Marks

1. A scar on the right side of the Fore - head

2. A black mole on the right hand elbow joint

/ ATTESTED /

Page 6 / 8
DETAILS OF SERVICE:
1. Date of Beginning of Service : 21.08.1995
2. Date of Retirement : 31.07.2002
3. Total Service : 6Y.11M.10D
4. Dis qualifying Service : Nil
5. Net qualifying Service : 6Y.11M.10D

Head of Office
DETAILS OF FAMILY MEMBERS:
_____________________________________________________________________________________
S.No Name Relationship Date of Birth / Age Martial Status
_____________________________________________________________________________________
1. TMT.G.PARIJATHAM WIFE 62 Yrs --
_____________________________________________________________________________________
2. TMT.G.SUBHASHINI DAUGHTER 37 Yrs Married
_____________________________________________________________________________________
3. TMT.SHOBANA DAUGHTER 37 Yrs Married
_____________________________________________________________________________________

Signature of Applicant

/ ATTESTED /

HEAD OF OFFICE

Page 7 / 8
WHEREAS THE TAHSILDAR, COIMBATORE SOUTH
has consented to grant me the sum of Rs.1275.00 (Rupees One Thousand Two Hundreds &
Seventy Five only) as the amount of my Pension with effect from 1.08.2002 and the sum of Rs.
(already authorised by the Accountant General, Chennai) in Ref. No. PEN. I/III /G.107/2115 / 2002-
2003 Dt.17.02.2003

As the amount of Death - Cum- Gratuity. In accepting the said amount I fully
understand that the said amounts are subject to revision the same being found to be in excess
to which I am to refund entitled to under the Rules and I promise to have no objection to such
revisions. I further promise any amount paid to me in excess of that to which I may be
eventually found entitled.

Signature of the Applicant

/ ATTESTED /

DECLARATION

I hereby certify that as per G.O. Ms. No.845, Finance Department dated
29.10.1985 I am waiting to make good the loss caused to Government if any by
way of my withdrawal of pay and allowances or leave salary or any other
admitted claims due to a result of my negligency or fraud on my part while in
service, either in lumpsum or in easy installments.

Signature of the Applicant

/ ATTESTED /

Page 8 / 8

(Vide G.O. Ms. No. 678, Revenue (ser.8 (2) Department Dt.16.11.2007)
 PENSION CALCULATION SHEET

1. Name : THIRU S.GOVINDARAJU

2. Designation : VILLAGE ADMINISTRATIVE OFFICER
3. Date of Birth : 10.07.1944
4. Date of entry into service : 21.08.1995
5. Date of Retirement : 31.07.2002

6. Length of qualifying service Reckoned for Pension and Gratuity

Years Months Days
7. Emoluments reckoned 06 11 10
for calculation of Pension
Last Pay Drawn : Rs.3968.00
Dearness Allowances: --
8. (1) Emoluments reckoned
For Pension : Rs.3968.00
(2) Pension Proposed: Rs.1275.00 (Vide G.O.Ms.No678, Rev.(ser.8(2)
Dept.Dt.16.11.2007
9. (a) Emoluments for Gratuity: Already sanctioned by A.G.Chennai
Last Pay : Rs.3968.00
Dearness Allowance : Rs.1786.00
Total: Rs.5754.00
(b) Retirement Gratuity : DCRG Rs.20139.00 & service Gratuity Rs.40278.00
Admissible already authorised by the AG,Chennai (as in Col.13)
10.(a) Emoluments for Family
Pension :
(1) Pay last drawn : Rs.3968.00
(2) Dearness Pay : ..
(3) Total : Rs.3968.00
4. (a) Ordinary Family Pension
At 30% Rs.1275.00
(b) Enhanced Family Pension Rs.1275.00

HEAD OF OFFICE