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APPLICATION FOR PENSION AND DEATH- CUM - RETIREMNET GRATUTITY

1. Name : THIRU S. GOVINDARAJU


2. Father’s Name and Husband name’s : THIRU SENNKRISHNA NAIDU
3. Religion and Nationality : INDIAN - HINDU
4. Present Address : SANTHAMANAICKENPALAYAM
DASANAICKEN PALAYAM (PO)
POLLACHI TALUK-COIMBATORE DIST
PIN: 642 202
5. Present Appointment including
The name of the Establishment : VILLAGE ADMINISTRATIVE OFFICER
KANNAMPALAYAM, PALLADAM TALUK
COIMBATORE DIST

6. Date of beginning of service : 21.08.1995


7. Date of Retirement : 31.07.2002
8. Total period of Military Service : Nil
9. Length of service with details
of Interruptions : Y.. M.. D..
Total Service : 6.11.10
Dis- Qualifying Service : Nil
Net Qualifying Service : 6.11.10
10. Class of Pension and Gratuity applied
For and cause of application : SUPERANNUATION & D.C.R.G
11.Emoluments reckoned for Pension : Pay : Rs.3795 + PP.Rs.173
12.Pension Proposed : Rs.1275.00 (vide G.O. Ms.No.678, Revenue
(ser.8 (2))
Department dated: 16.11.2007
13.Proposed Gratuity : Rs.20139.00 and Service Gratuity
Rs.40278.00
already authorised vide A.G’s Ref. No.
PEN.I /III /G.107/2115/2002-2003 dt: 17.2.2003
14.Date from which Pension is to
Commence : 1.8.2002
15.Place of Payment : For Pension:
Sub Treasury, Coimbatore South.
16.Place of Payment : For D.C.R.G (As in col.13 - already authorized
by the Accountant General)

Signature of the Applicant


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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

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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

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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 /

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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 /

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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

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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 /

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(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