A.

1 Name (in Block letters)

2 Designation

3 Employee No.

4 Father’s Name

5Husband’s Name (in case of female employee)

6 Religion

7 PF A/c No. (also specify the previous EPF/CPF/GPF A/c No. if any)

8 Name of Office/Deptt. last served

9 Date of Retirement

10 Date of Death (wherever applicable)

B.

11 Permanent address

12Present address for communication after retirement

13 Telephone no.with STD code (if any)

14 Mobile No.

15 E-mail address (if any):

16 PAN No.

17Savings Bank A/c No. (Single or joint account with spouse)

18 Name of the Bank

19 Name & Adress of the Branch

20 i) IFSC code & ii) MICR Code

21Name of the Unit: (where Life certificate/Income tax declaration to be submitted)

22Particulars of previous civil service if any And amount and nature of any pension Or gratuity received

23

Particulars of family pension if any Received/admissible from any other Source to the retired employee and Any members of his family.

24Whether Commutation of pension to be made & percentage to be specified- (not applicable for applicants for family pension)

ODISHA POWER TRANSMISSION CORPORATION LTD Regd Off- Janpath,Bhubaneswar-751022

PENSION/FAMILY PENSION PROPOSAL FORM (Provisional/Final/Revised) PART-I

(To be completed by the Employee/Applicant for sanction & payment of Pension/Family pension,Death-cum-retirement Gratuity ,Service Gratuity & Commuted value of pension)

PERSONAL DETAILS OF THE APPLICANT FOR PENSION/FAMILY PENSION

PARTICULARS OF EMPLOYEE/EX-EMPLOYEE

YES/No

i) ii)

C.

25Name of the applicant who is eligible for Family Pension ( in case of death of the employee )

26Relationship with the deceased employee

27Date of Birth of the applicant (Family Pensioner)

28If the applicant for family pension is employed,particulars of his/her employment

29If the applicant for family pension is in receipt of pension from any other source,particulars of such pension

30Name and relationship with the minor child, ( if the applicant is legal guardian )

D.

31

Sl No Full Name of the family member

Date of Birth (Proof of the same to be

furnished by the applicant )

Relationship with the retired employee

Total income per annum

Other remarks and physically handicapped status if any Marital status

1 2 3 4 5 6 7

32

Sl No. Full Name and AddressRelationship with the Retd. Employee

Date of Birth

Amount/ Share payable to each

1 2 3 4 5

Particulars of nominee (any one or more than one member of the family) who shall receive the gratuity, commutation amounts (if becomes absolute) and arrears of pension in case of death of the retired employee before the amounts become payable or having

become payable & have not been paid:

(A) Details of Family as on the date of application:- In case of having 2nd spouse, the proof of death of fisrt spouse and their children may be specified and enclosed)

6

Particulars of the applicant applying for Family Pension (sl no. 25 to 30 - NOT APPLICABLE FOR SERVICE PENSIONERS)

DETAILS OF FAMILY MEMBERS & NOMINATION

Name relationship, age & address of the person, who shall

receive the amounts during nominees minority.

E.

a) Death Certificate

b) Legal Heir Certificate

Place:

Date:

Name & Designation Office address

Witness (i)

Witness (ii)

(xiii) Any other document (s) may be attached if relevant for sanction & payment of pension/family pension as per OCS Pension rules-(Specify)

(ix) Certificate from the Medical Board in case of physically handicapped/mentally retarded applicant.

Signature

DECLARATION

I do hereby declare that the particulars furnished above are true in all respects. I also undertake to keep the particulars of family, nominee and postal address of self up to date by notifying all changes therein to the Head of Office(pension controlling Unit) with a copy to Funds section.Further I do hereby undertake that if any excess payment is made to me and is detected at any stage,the same shall be recovered from any dues payable to me or to my family members at any time in future.

Signature of Head of Office with designation

(ii) Three descriptive roll slips each bearing three specimen signature (L.T.I. if illiterate). Particulars of height and identification marks (at least 2 conspicuous marks) and left hand thumb and all fingers impression of the applicant duly attested by the head of office.

c) Power of attorney (authorising one of the eligible family pensioner to receive the entire claim on behalf of the family members)-if applicable

(iii) Attested copies of date of birth certificates of all family members & nominee(s).

(vii)  Attested copies of (Applicable for Family Pension)

(xi) Attested copy of PAN Card where the pensioner is coming under Income Tax bracket.

(x) Affidavit of being unmarried,unemployed,income certificate,etc by the son or daughter applying for family pension as per rules.

(xii) Proof of identity viz.:Attested copy of Voter I.Card/Adhar Card

(viii) Guardianship Certificate from theCompetent Authority for receiving the pensionary benefits on behalf of minors and mentally retarded child (Attested photographs of both the applicant and the child is to be submitted)

LIST OF DOCUMENTS. (To be submitted by the applicant for service or family pension as per applicability )

Signature of the Retired Employee/ Applicant for Family Pension

Submitted (Yes/No/NA)

(iv) Undertaking/Declaration for refund/recovery of outstanding dues/excess payment wherever applicable.(v) Attested copy of the first page of Bank Pass book with IFSC and MICR code alongwith copy of the cancelled cheque issued by the concerned Bank.

(i)Three recent passport size joint photographs with spouse (if married) and Single photograph of self (applicant) duly attested.

(vi) Indemnity Bond (For the PF A/C which have not been transferred from the RPFC)

PART-I-A

ACKNOWLEDGEMENT

Received the pension proposal form alongwith all relevant enclosures from Sri/Smt._______________________________________________ ,Retd_______________ on Dt.___________________.

Place:- Date:-

Signature of Head of Office with seal

1

2

3

4

5

6

Post HeldFrom Date To Date Years Months Days

9

10

11

YES/NO

Date Of Birth of Employee

Date of Death

Pension Proposal Form Part-II(To be completed by the Head of Office/Executive Establsihment/ Non-Executive Establishment

as the case may be)

Period

Service rendered in various offices /Posts

Whether all the periods of absence including participation in strike,etc.have been regularised by grant of leave or otherwise.(Specify the periods)

Signature of the Head of Office With Designation /

Superannuation/VRS/ Compulsory retirement/Family Pension/Invalidation/Any others

Period of service

NO DEMAND CERTIFICATE

Head of NEE/EE Branch of OPTCL Head Qrs,Bhubaneswar.(Strike out whichever is not applicable)

Last Basic Pay + Grade Pay as on the date of retirement/cessation of service

Recommended for provisional Pension

There is nothing outstanding against Sri/Smt. , (Name & Designation of Ex-Employee) (Unit name) so far as the GRIDCO/OPTCL is concerned / except (specify)

OR

Reason for non issue of NDC

Whether the entire service period is duly covered by service verification Certificate.(Specify the periods not verified)

Status of departmental or judicial proceedings instituted/contemplated Or to be instituted against the employee if any.

Organisation

8

6

7

Date of Joining

Class of pension applicable

Pay Band /Scale of Pay

Date of Retirement/ Cessation of service

Name of office

1 Date of Birth in Christian era

2 Date of beginning of service

3 Date of retirement/ Ceasation of Service

4 Date of death

Year Month Day

5 Period of gross qualifying services

6Less Period of non-qualifying service

i) Interruption in service condoned

ii)Extraordinary leave not qualifying for pension

iii)Period of suspension not treated as qualifying service

iv)Work charged service period not treated as qualifying service

v)Boy service period if not treated as qualifying service

vi)Any other service not treated as qualifying service

TOTAL ( i) to (vi)

7 Qualifying service (5-6)

8 Add Addition to qualifying service if any

9 Net Qualifying service (7+8)

10 Total Qualifying service for pensionery benefits (Expressed in half years)

11Emoluments (Last Basic Pay + Grade Pay)

12 Pension/Family pension

13Date of commencement of Pension/Family pension

14 Date of acknowledgement for commutation

Pension Proposal Form Part-III

FINAL/PROVISIONAL/REVISED

(To be completed by the HR Pension Cell)

15 Age as on next Birthday

16 Commuted factor applicable

17 Commuted amount of pension

18 Commuted Value of pension

19 Residuary pension after commutation

20 Amount of Death cum retirement gratuity (DCRG)

21 Family pension Amount

a) Enhanced family pension

b) Normal family pension

22 Life time arrear pension/family pension(if any)

23

Particulars Amount

i)

ii)

iii)

iv)

v)

vi)

Head of HR Pension Cell

Outstanding dues for recovery/withheld from DCRG and pensionery benefits

Up to

Remarks (rate of interest to be charged, & effective dates if any

may be specified)

Sl No Particulars Remarks

1 Pension Payment Order No (PPO)

2 Employee No.

3 Name

4 Designation

5 Name of the Unit (Last Worked)

6 Name of the Unit where PPO is to be sent

7 Gross Qualifying Service (in half years)

8 Net qualifying Service (in half years)

9 Emoluments (Last Basi Pay + Grade Pay)

10 Amount of Service pension

11Date of commencement of Pension/Family Pension

12 Percentage of Pension to be commuted

13 Commuted amount of Pension

14 Commutation Factor

15 Commuted value of Pension

16 Reduced Basic Pension after commutation

17 Family Pension Amount Effective Date Up to

18 Enhanced rate of Family Pension

19 Normal rate of Family Pension

20 Death cum retirement Gratuity

21 Recoveries/Withheld amounts

i) PF Employer share

ii) Interest theron if any

iii) Industrial Gratuity

iv) Interest theron if any

v) Other deductions as per LPC/NDC

Total deductions

22 Savings Bank Account No

23 Bank Name

24 Branch Name

25 Address of The Branch

26 Branch Code

27 IFSC code

28 MICR Code

Pension Proposal Form Part-IV(To be completed by Funds Pension Branch )

Head of Funds Section

A)

1 FULL NAME

2 P.P.O. NO.3 DATE OF DEATH

B)1 NAME OF THE APPLICANT

2 RELATIONSHIP WITH THE DECEASED PENSIONER

3IF THE APPLICANT IS EMPLOYED,PARTICULARS OF HIS/HER EMPLOYMENT

4

IF THE APPLICANT IS IN RECEIPT OF PENSION FROM ANY OTHER SOURCE,PARTICULARS OF SUCH PENSION

5 COMPLETE POSTAL ADDRESS OF THE APPLICANT

6 SAVINGS BANK ACCOUNT NO

7 NAME OF THE BANK

8 BRANCH NAME

9 IFSC & MICR CODE

10 ADDRESS OF THE BANK

11a

b Attested Copy of Voter I.Card/Aadhar card

c

d Undertaking for recovery of excess payments,if any

e

f

g

Place:

Date:

APPLICATION FOR GRANT OF FAMILY PENSION TO THE WIDOW/WIDOWER OF A DECEASED PENSIONER

PARTICULARS OF THE DECEASED PENSIONER

PART-I-B

Signature or left thumb impression of the applicant

ENCLOSURES

Attested copy of death certificate

Identification documents of the applicant viz.: Two recent passport size photographs(attested on backside),two slips bearing specimen signatures or left thumb impressions and two slips bearing the present height and identification marks (at least two conspicuous marks) of the applicant

PARTICULARS OF THE APPLICANT

Attested copy of Legal her certificate

i) ii)

Attested copy of the Pension Payment OrderPower of attorney (authorisation to receive the dues of the deceased pensioner by the family members)-if applicable