Details of Family of Government Servant

DETAILS OF FAMILY OF GOVERNMENT SERVANT

1. Name of the Government Servant :

2. Designation :

3. Date of birth :

4. Date of appointment :

5. Details of the members of my family as on:- ______

______

------S.No Name of the Date of birth Relationship Initial of the member of with the Govt head of the Office family. Servant ------

I hereby undertake to keep the above particulars upto date by notifying to the audit office/bead of Office any addition or alteration.

Place:- Bandipur Signature of Govt Servant

ATTESTED Form – 6 NOMINATION FOR BENEFITS UNDER THE CENTRAL GOVT EMPLOYEES INSURANCE SCHEME.

When the Govt servant has family and wishes to nominate one member or more than one member thereof.

I, hereby nominate the person(s) mentioned below, he/she/they is/are member(s) of my family and confer on him/them the right to receive the extent specified below any amount that may be sanctioned by the Central Govt under the Central Govt Employed Group Insurance Scheme 1990 in the event of my death while in service or which having become payable on my attaining the age of superannuation may remain un paid at my death.

------S.No Name and address of nominee/nominees Relationship with Govt servant Age ------

------Share to be paid Contingencies on the happening of Name, address and relationship of to each which the nomination shall become the person if any, to whom the invalid. nominee shall pass in the event of his predeceasing the Govt Servant ------

------NB: The Govt Servant should draw line across the blank space below his last entry to prevent insertion of any names he has signed.

Dated this______day ______2003______At______

Signatures of two witness

1.------

2.------

Signature of Govt servant

------This column should be filled in so as to cover the whole amount that may be payable under the Insurance Scheme. FORMS OF NOMINATION FOR G P FUND First Schedule ( Rule 5 (3) )

When the subscriber has no family and wishes to nominate one person.

I having no family as defined in Rule 2 of the General provident Fund (Central Services ) Rules 1960, hereby nominate the person mentioned below to receive the amount that may stand to my credit in the Fund, in the event of my death before that amount has become payable, or having become payable has not been paid.

Name and address of Relationship Age Contingencies on the Name, address and Nominee with happening of which relation-ship of the subscriber the nomination shall person/persons if any to become invalid whom the right of the nominee shall pass in the event of the nominee predeceasing the subscriber

Dated this ______day of______2003 at______

Two witnesses to signature

1. No.______Rank______

Name______Signature of Subscriber 2. No.______Rank______No.______

Name______Rank______

Name______

ATTESTED FORM – ‘E’

NOMINATION FOR FAMILY PENSION

I. No.______Rank______Name ______hereby nominate the persons mentioned below, who are members of my family to receive in the order shown below, the family pension which may be granted by govt in the event of my death after completion of 10 yrs qualifying service. ------S/No. Name & Address Relationship Date of Whether of Nominee with subscriber birth/age married/unmarried ------

------NB. The subscriber should draw lines across blank space below the last entry in prevent the incretion of any name after he has signed.

This nomination supersedes the nomination made by earlier on______which stands cancelled

Dated, this______Day of______month______year______.

Witness:-(Name and Signature.)

1.No.______Rank______Name______Sig______.

2.No.______Rank______Name______Sig______.

Signature of Individual

------

( To be filled in by the Head of Office in case of death) NOMINATION FOR FINANCIAL ASSISTANCE OUT OF BSF BEN FUND

No. ______Rank______Name______

______here by nominate the person/persons mentioned below who is/are member of my family and to confer the right to receive the financial assistance from BSF Ben fund that may be sanctioned by the Government in the event of my death.

Name and address Relationship age Contingencies on the happening of of nominee which the nomination shall become invalided. ------

------The details of my family members are as under:-

Father______

Mother______

Children

1.______Date of birth______

2. ______

3. ______

4. ______

COUNTER SIGNED Signature of Govt servant ( in block letter )

IRLA. No______

Rank ______

Name ______NOMINATION FOR DEATH-CUM-RETIREMENT GRATUITY

When the Officer has a family and wished to nominate one member thereof.

I Hereby nominate the person mentioned below, who is a member of my family, and confer on him the right to receive any gratuity that may be sanctioned by Government in the event of my death while in service and the right to receive on my death any gratuity which, having become admissible to me on retirement, may remain unpaid at my death.

Name and address Relationship Age Contingencies on the Name, address and relationship of the Amount for share of of nominee with Officer happening of which person or persons if any, to whom the gratuity payable to the nomination right conferred on the nominee shall each shall become invalid. pass in the event of the nominee predeceasing the officer or the nominee dying after the death of the Officer but before receiving payment of the gratuity.

This nomination supersedes the nomination made by me earlier on ______which stand cancelled

PROFORMA FOR ACKNOWLEDGING THE RECEIPT OF THE NOMINATION FORM BY THE HEAD OF OFFICE/AUDIT OFFICER.

------

In acknowledging the receipt of your nomination dated ______cancellation dated

______of the nomination made earlier, in respect of D.C.R.G in Form

______I am to state that they have been duly placed on record.

Date______Signature of Head of Office Designation ______