FORM-7 [See rule 57, 58(6), 61(1), 63; 64(2) and (3), 68 (1) and (7)]

FORM FOR ASSESSING PENSION AND GRATUITY (To be sent in duplicate if payment is desired in a different circle of Audit)

PART - I

1. Name of the Government Servant

:

2. Father’s name (and also husband’s Name in

the case of female Government Servant)

:

3. Date of Birth (by Christian Era)

:

4. Religion

:

5. Permanent residential address showing village, town

district and state

:

6. Present or last appointment including name of the

establishment

(i) Substantive

(ii) Officiating, if any

:

7. Date of beginning of service

:

8. Date of ending of service

:

9. (i) Total period of military service for which pension

or gratuity was sanctioned.

(ii) Amount and nature of military pension gratuity

received from the military services.

:

10. Amount of and nature of any pension/gratuity received

for previous civil services.

:

11. Government under which services has been rendered in

order of employment

:

12. Class of pension applicable.

:

13. The date on which action initiated to :

(i) Obtain the ‘No demand certificate from the

department in charge of building as provided

in rule 52*

(ii) Assess the service and emoluments

qualifying for pension as provided in rule 57

and 61*

:

(iii)Assess the government dues other than the

dues relating to allotment of government

accommodation.

14. Details of omissions, imperfections or deficiencies in

the service book which have been ignored.

:

15. Total length of qualifying service (for purpose of adding

towards broken periods, a month is reckoned as thirty

days).

:

From To

16. Period of non-qualifying service :

(i) Interruption in service condoned under Rule 25*

(ii) Extraordinary leave not qualifying for pension

(iii)Period of suspension not treated as qualifying.

(iv) Any other service not treated as qualifying

:

17. Emoluments reckoning for Gratuity

:

18. Average emoluments “emoluments drawn during the last ten months of service:

Post held From To Pay Personal or Special Pay

19.

(i) In a case where the last ten months include

some period not to be reckoned for calculating

average emoluments, an equal period backward

has to be taken for calculation average

emoluments.

(ii) The calculation of average emoluments should

be based on actual number of days in each

month.

(*Tamil Nadu Pension Rule 1978)

Date on which Form 5 has been obtained from the

Government servant (to be obtained on year before

the date of retirement of Government servant)

:

20. Proposed pension.

:

21. Proposed death-cum-retirement Gratuity.

:

22. Date from which pension is to commence.

:

23. Proposed amount of provisional Pension if

department or judicial proceeding is instituted

against the Government Servant before retirement.

:

24. Details of Government dues referred to in rule 70

recoverable out of gratuity.

:

25. Whether nomination made for :

(i) Death-cum-Retirement gratuity.

(ii) Non-contributory family pension, if

applicable.

:

26. Whether contributory family pension applies to the

government servant and if so:

(i) Emoluments reckoning for the family

pension.

(ii) The amount of the family pension

becoming payable to the family of the

government servant, if death takes place

after retirement.

(iii)Complete and up to date details of the

family as given in Form 3

:

Serial

Number

Name of the family members Date of birth Relationship with the

Government Servant

1 2 3 4

1. 2.

3. 4.

27. Height

:

28. Identification marks

:

29. Place of payment of pension (Treasury, Sub-

Treasury or Pay and Accounts Office)

:

30. Head of account to which pension and gratuity are

debitable.

:

:

Signature of the

Head of Office

FORM 1-A

FORM OF APPLICATION FOR COMMUTATION OF A FRACTION OF SUPERANNUATION PENSION WITHOUT MEDICAL

EXAMINATION WHEN APPLICANT DESIRES THAT THE PAYMENT OF THE COMMUTED VALUE OF PENSION SHOULD BE AUTHORIZED THROUGH THE PENSION PAYMENT ORDER

[see Rule 5(2), 12,13(30,14(i) and 15(3)]

(To be submitted in duplicate at least three months before the date of retirement)

PART I

To, (Here indicate the designation and full address of the Head of Office)

Subject : Commutation of pension without medical examination. Sir, I desire to commute a fraction of my pension in accordance with the provisions of the Central Civil Services (Commutation of Pension) Rule, 1981. The necessary particulars are furnished below-

1. Name (in Block letters)

2. Father’s name (and also husband’s name in the case of a female Government Servant)

3. Designation

4. Name of Office/Department/Ministry in which employed

5. Date of Birth (by Christian era)

6. Date of retirement on superannuation or on the expiry of extension in service granted under FR 56 (d)

7. Fraction of superannuation pension proposed to be commuted (The applicant should indicate the fraction of the amount of monthly pension subject to be maximum of forty percent thereof which he/she desires to commute and not the amount in Rupees)

8. Disbursing authority from which pension is to be drawn after retirement (score out which is not applicable)-

(a)

Treasury/Sub-treasury (name and complete address of the Treasury/Sub-Treasury to be indicated)

(b) (i) Branch of the nominated nationalized bank with complete postal address. (ii)Bank Account No. to which monthly pension is to be credited each month.

( c) Account Office of the Ministry/Department/Office

Signature

Present Postal Address

Postal address after retirement

Place :

Date :

Footnote : 1. The applicant should indicate the fraction of the amount of monthly pension (subject to a maximum of one-third thereof) which he/she desire to commute and not the amount in rupees. 2. Score out which is not applicable.

PART II

(ACKNOWLEDGEMENT)

Received from Shri/Smt/Kumari

(Name)

(designation)

Application in Part I of Form I-A for commutation of a fraction of pension without medical examination.

Place :

Signature Head of Office

Date :

NOTE – If the application has been received by the Head of Office before the date of retirement on superannuation, this acknowledgement should be detached from the Form and handed over to the applicant, If the form has been received by post, it has to be acknowledged on the same day and the acknowledgement sent under registered cover to the applicant. In case it is received after the specified date, it should be accepted only if it has been put into the post on or before that date subject to the production of evidence to that effect by the applicant.

PART III

Forwarded to the Account Office,

(here indicate the address and designation With the remarks that-

(i) the particular furnished by the applicant in Part I have been verified and are correct; (ii) the applicant is eligible to get a fraction of his pension commuted without medical examination; (iii) the commuted value of pension determined with reference to the table applicable at present comes

to Rs. and

(iv) the amount of residuary pension after commutation will be Rs.

2. The pension papers of the applicant completed in all respects were forwared under this Ministry

Department/Office Letter No. Dated

It is requested that the payment of commuted value of pension may be authorized the Pension payment Order which may be issued one month before the retirement of the applicant.

3. The receipt of Part I of this Form has been acknowledged in Part II which has been forwarded separately to the applicant on

4. The commuted value of pension is debitable to Head of Account

Place :

Signature Head of Office

Date :

FORM – 5

[(See Rules 39(I) (e) and 01(I)]

Particulars to be obtained by the Head of office from the retiring Government servant eight months the date of his

retirement:

1. Name ………………………………………………. 2. (a) Date of birth ………………………………………………. (b) Date of retirement ……………………………………………….

© H.R. No. …………………………………………………

(d) PAN NO. …………………………………………………

(e) Aadhar No. ……………………………………………………

(f) Mobil No. …………………………………………………….

(g) E-mail Add. …………………………………………………….

Two specimen signature ( to be furnished in a separate sheet ) duly attested by a Gazetted Govt. Servent -

Three copies of passport size joint photographs with wife or husband (to be attested by the Head of the office) – 3. Two slips showing the particulars of height and personal identification marks duly attested by a Gazetted

Government Servant -

5. Present address

6. Address after retirement

7. Name of the Treasury or the Branch of Public Sector Bank or the Pay and Accounts office through which the

pension is to be drawn. : 8. Details of the family in Form- 3

Place: Signature :

Date : Designation :

Ministry / Deptt / Office : BSNL

1. Two slips each bearing the left-hand thumb and a person whom is not literate to sign his name may furnish

finger impression duly attested. If such a Govt Servant on account of physical disability is unable to give left

hand thumb and finger impression he may give thumb and finger impression of the right hand. Where a Govt.

Servant have lost both of the hands he may give his toe impressions. A Gazetted Govt. Servant may attest

impressions.

2. Two copies of the pass port size photograph of self only need be furnished.

(i) If the government servant is governed by the rule 54 of the Central Civil Services (Pension), 1972 and he is

unmanned or a widower or widow.

(ii) If the Govt. Servant is governed by rule 55 of the Central Civil Services (Pension), 1972.

3. Where it is not possible for a Govt. Servant to submit a photograph with his wife or her husband, he or she may

submit separate photograph. The head of office shall attest the photograph.

4. Specify a few conspicuities marks not less then two if possible.

FORM – 3

DETAILS OF FAMILY

Name of Government Servant Designation Date of Birth Date of Appointment Details of member of my family* as on

Sl. No. Name of the Members of Family Date of Birth Relationship

with the official

Initial of the Head of

Office

Remarks

I hereby undertake to keep the above particulars up-to-date by notifying to audit officer/Head of office any addition

or alteration.

Place : Signature of the Govt. Servant :

Date :

Designation :

(a) PAN NO.

(b) Aadhar No.

(c) Mobil No.

(d) E-mail Add.

*Family for this purpose means:

1. Wife, in the case of male Government Servant

2. Husband, in the case of female Government Servant

3. Sons below eighteen years of age and unmarried daughter below twenty years of age including such son or

daughter adopted legally before retirement.

NOTE : Wife and husband shall include respectively judicially separation of wife and husband.

FORM

[SEE RULE 53(I)]

NOMINATION FOR DEATH-CUM RETIREMENT GRATUITY

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

I, ………………………………..…. hereby nominate the person (s) mentioned below, who is /are member (s) of my family

& confer on him / her right to receive to the extent specified below any amount that may be sanctioned by the Central

Government under the Central Government Employee Group Insurance Scheme 1980 in the event of my death while in

service or which having become payable on my attaining of superannuation unpaid at my death.

Original nominee (s) Alternate nominee (s)

Name and Address of the

nominee/ nominees

Relations

hip with

the

Governm

ent

Servant

Age Amount

of share

of

Gratuity

payable

to each

Name, address, Relationship of

person if any, to whom the

right conferred on the nominee

shall pass in the event of the

nominee pre –deceasing the

Govt. Servant or nominee

dying after the death of the

Govt. Servant but before

receiving payment of Gratuity

Dat

e of

Bir

th

Amount of

share of

gratuity

payable to

each

(1) (2) (3) (4) (5) (6) (7)

This nomination supersedes the nomination made by me earlier , which stands cancelled.

Note :

(i) The Government Servant shall draw lines across the blank space below his last entry to prevent the insertion

of any name after he has signed

(ii) Strike out which is not applicable.

Dated the :

Signature of two witnesses:

1 …………………………

2 …………………………

Signature of Government Servant

(To be filled by the Head Office)

Nomination by ……………………….. Signature of Head Office

Designation ………………………….. Date ……..

Office …………………………….. Designation ………………

FORM NO. 8

NOMINATION FOR BENEFITS UNDER CENTRAL GOVERNMENT EMPLOYEES GROUP INSURANCE

SCHEME, 1980

(When the Government Servant has a family and wishes to nominate one member or more than one thereof)

I, GIRISH KUMAR SINGH hereby nominate the person (s) mentioned below, who is / are member (s) of my family &

confer on him / her the right to receive to the extent specified below any amount the may be sanctioned by the Central

Government under the Central Government Employees Group Insurance Scheme, 1980 in the event of my death while in

service or which having become payable on my attaining age of superannuation may remain unpaid at my death.

Name and address of nominee (s) Relationship

with Govt.

Servant

Age *Share

to be

paid in

each

Contingencies on

the happening of

which the

Nomination shall

become invalid

Name. address and

relationship of the person if

any, to whom the right of the

nominee shall pass in the

event of his predeceasing

the Govt. Servant

(1) (2) (3) (4) (5) (6)

N.B. The Government Servant should draw line across the blank space below his last entry to prevent insertion of any

names after he has signed.

Dated the

Signature of two witnesses:

1. ……………………….

2………………………

Signature of the Government Servant

*This column should be filled in so as to cover the whole amount that to be payable under that insurance scheme.

FORM – 5

(See Rule 7)

Head of Office :

I, ……………………………….. (Name of the pensioner in Capital letters) hereby nominate the person named below,

under Rule 7 of Central Civil Services ( Commutation of Pension ) Rules, 1981.

Name and address of

nominee

Relationsh

ip with the

pensioner

Date of

Birth

If nominee is minor Relations

hip with

the

pensioner

Date of

birth if the

other

nominee is

minor

Name & Address

of person who

may receive the

said commuted

value during the

nominee’

minority

Name & Address of

nominee in case the

nominee under

column (i)

predeceases the

pensioner

1 2 3 4 5 6 7

Place :

Date :

Witness Signature:

Name and address :

Signature (or thumb impression if illiterate) and

Name of pensioner :

Address:

Signature of Head of Office

Stamp

Acknowledgement to be sent by the Head of Office

Certified that the nomination has been received from …………………………… ……(Name of pensioner) whose address is

………………………………………………

Place ………………

Date …………..

Signature of Head of Office

Full Address

[G.I.] Dept of Pension and Pensioners’ Welfare Nomination No. 34(5)/83-Pension Unit, date the 17th April, 1985, published

as SO 1870 in the Gazette of India dated the 4th May, 1985]

FORM – A

(See Rule 5)

Pension Disbursing Authority /Head of Office:

(Name of Bank /Treasury/Post Office/Account Officer etc)

I, ……………………………………. (Name of the pensioner in Capital letters) hereby nominate the person named below,

under Rule 5 of the payment of Arrears of Pension (Nomination) Rule, 1983.

Name and address of

nominee

Relations

hip with

the

pensioner

If nominee is minor Name and Address of

nominee in case the

nominee under

column (1)

predeceases the

pensioner

Relationship

with the

pensioner

Date of

birth if the

other

nominee is

minor

Date of

birth

Name and

Address of

person who

may receive

the said

commuted

value during

the nominee’s

minority

Place : Date :

Witness Signature :

Name and address:

Signature (or thumb impression if illiterate) and

Name of pensioner : Address:

Signature of Pension Disbursing Authority / Head of office

Stamp

Acknowledgement to be sent by the Head of Office

Certified that the nomination has been received from Shri ----------------------- (Name of pensioner) whose address is --------

-------------------------------------------------------------------------------------------

Place : ………………………

Date : ………………………

Signature of Pension Disbursing

Authority/Bank/Treasury/Post Office/Account Officer,

Head of Office

Full Address

FORM OF NOMINATION FOR G.P.F.

I hereby nominate the person mentioned below, who is a member of my family as defined in Rule 2 of G..P.F. (CS) Rule,

1960 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

nominee

Relationship

with

Subscriber

Age Contingencies on the

happening of which the

nomination shall become

invalid

Name of the person/persons, if any to

whom the right of the nominee shall pass

in the event of his predeceasing the

subscriber

Dated : at

Attested by Head of Office

Signature of subscriber

GPF A/C No.

Accepted

Account Officer

Bharat Sanchar Nigam Limited (A Govt. of India Enterprise)

(In duplicate)

Height and identification mark details of Shri

Height

Identification Mark

Attested by

Bharat Sanchar Nigam Limited (A Govt. of India Enterprise)

(In duplicate)

Specimen Signature of Shri

1 ……………………….

2 ……………………….

3 ……………………….

Attested by

Passport Size Photograghs with wife ( ATTESTED)

1. Photograph of Shri…………………………………with wife H.R. No……………….

Photograph Attested by

2. Photograph of Shri…………………………………with wife H.R. No……………….

Photograph Attested by

2. 3. Photograph of Shri…………………………………with wife H.R. No……………….

Photograph Attested by

भविष्य निधि

भविष्य निधि खाते में शेष रकम के अंनतम भुगताि हेतु आिेदि – पत्र का प्रपत्र

सेवा में, लेखाधिकारी(कैश), कार्ाालर् मुख्र् महाप्रबंिक दरूसंचार, (पूवी) पररमण्डल उ०प्र० हजरतगंज लखनऊ ।

महोदर्, मै ददनांक ......................... अपराहन को सेवाननवतृ्तत हो जाऊँगा । जन्मनतधि ...................

अतः ननवेदन है कक ननर्मानुसार ब्र्ाज सदहत मेरे खाते में जमा कुल िनराशश का मुझ ेभुगतान करने कक कृपा करें ।

मेरी भववष्र् ननधि खाता संख्र्ा ..............................एवं एच० आर० नं० ............................ है । मै अपने कार्ाालर् कार्ाालर् मुख्र् महाप्रबंिक दरूसंचार, पूवी उ०प्र० पररमण्डल लखनऊ के माध्र्म से भुगतान प्राप्त करना चाहता हँू ।

मेरे व्र्त्ततगत पहचान वववरण बार्ें हाि के अगूंठे के अिवा अगंुशलर्ों के ननशान (ननरक्षर अशंदाता) के मामले में तिा नमूने के हस्ताक्षर ( साक्षर अशंदाता के मामले में ) तिा सरकारी राजपत्रित अधिकारी द्वारा ववधिवत सतर्ावपत कराकर दो प्रनतर्ों में संलग्न है ।

स्िान : आपका

हस्ताक्षर

ददनांक : नाम.................................................................. पता.................................................................. फोन/ मोबाइल नं०..............................................

कृपया पेंशि प्रपत्र के साथ निम्ि लिखखत दस्तािेज संिग्ि करे

1- 06 फोटो साइज 5X8.5cm ( लसगंि/ज्िाइंट) जो भी हो । 2- आिार कार्ड ि पैि कार्ड की दो-दो प्रनतयााँ स्िप्रमाखित (पनत ि पत्िी दोिो की )

3- राष्रीयकृत बैक में खाता ि कैं लशि चेक हस्ताक्षर सहहत दो प्रनतयो में ।

4- CCA द्िारा जारी िामांकि पत्र फामड 1,2, ि 3 पूिड रूप से भर कर सक्षम अधिकारी से सत्यावपत करिा कर दो प्रनतयम में

5- VRS request and accepting letter.

P & GS MANDATE

ELECTRONIC MODE APPLICATION FORM To

The P & GS Unit Office

_________________________________ Luck now. Sub: Mandate for Electronic Mode

Sir, I/We give below the details required for payment through Electronic Mode. (Please √ appropriate item) (1) Master Policy No. / Annuity No.________________________________________ (2) Name of the Master Policy holder /Annuitant : _____________________________ (3) Bank Name : ______________________________________________________ (4) Bank Address : _____________________________________________________ (5) Account Type : Savings/Current/Cash Credit____ __________________________ (6) Account No. (7) IFS Code of the Bank : (8) MICR Code of the Bank :

(9) Contact Mobile No. : (10) E-Mail Id : _________________________________________________________

Kindly transfer amount due under the above Master Policy / Annuity. The following documents are enclosed as required. (Please √ appropriate item)

A. Cancelled cheque leaf

B. Photo copy of the first page of Bank pass book containing details (If cheque is not having the name of account holder)

_____________________

Signature Date :

FOR OFFICE USE ONLY

1) Name & SR No. of the Person Entering the data : 2) Date of Entry : 3) Name & SR No. of the Person validating : 4) Date of Validation :

+ 9 1

Life Insurance Corporation of India

(Established by the Life Insurance Corporation Act. 1956)

Divisional Office : Luck now

MASTER POLICY No……………….. CLAIMENT’S AND EMPLOYER’S STATEMENT

Part 1 : CLAIMNT’S STATEMENT

(To be completed by the Master Policyholder i.e. by Trustees of the scheme in the case of Group Gratuity &

Superannuation Schemes & by the Employer in case of other Group Insurance Schemes )

1. (i) Name of the Scheme

(ii) Master Policy No.

(iii) Full Name and address of

The Master Policyholder

2. (i) Full Name of the

deceased Member

(ii) Serial No. of the deceased in the

date for the policy year in which death

occurred .

3. (i) Date of entry into

Scheme by Member

(ii) Date of death of Member

(iii) Cause of death of Member

We hereby declare that the answers to all the above questions are true in every respect.

We enclose……………………………………….in original in proof of death of the Member.

PLACE……………………… (Signature of Master Policyholder)

DATE……………………… SEAL:

Please Specify the nature of proof submitted.

Life Insurance Corporation of India Part II : EMPLOYER’S STATEMENT

(To be completed by the Employer in a case where no individual evidence of health was obtained during

3 years prior death )

1. Name of the Employer:

2. (i) Full Name of the deceased Member.

(ii) Serial No. of the deceased in the data

for the policy year in which death occurred.

(iii) Date of entry into service.

(iv) Date last attended duties prior to Death.

(v) Date of Death.

(vi) Cause of Death.

(vii) Place of Death.

(viii) Was the member in the service of the

Employer on the date of death ?

(ix) Date of Birth.

Please give below the record of absences from duty by Member during the past 3 years prior to death :

Period No. of Nature of Leave reason as stated Remarks

From To days in Application Form

Please state whether Doctor’s Certificate was submitted in case of leave on grounds of health.

We hereby declare that the answers to all the above questions are true in every respect.

PLACE……………………… (Signature of Master Employer)

DATE……………………… SEAL:

ANNEXURE 1

Pensioner’s letter of Authority and Undertaking To, Date----- Pr.CCA/CCA ………………….. Sir,

I hereby opt to draw my Pension through a Bank Account under the direct disbursement of telecom pension by DOT through SAMPANN. I hereby authorize the bank to receive my monthly Pension on my behalf and credit the same to my account as per particulars given as follows:

a. Name of the Bank : b. Branch : c. Account No. : d. IFSC Code :

2) I hereby undertake that any amount of excess/wrong payment of pension, if credited to my Bank Account will be refunded on your instructions.

3) I undertake and agree to bind myself and my heirs, successors, executors and administrators to

indemnify the Bank/ PDA in so crediting my pension to my account under the scheme and to forthwith refund/pay any amount due from me to the Bank/PDA and also irrevocably authorize the Bank/PDA to recover, any amount due from me by debit to my said account or any other accounts/deposits belonging to me in possession of the Bank.

----------------------------------------------------

Signature of Pensioner Witnesses :- (1) Signature : (2) Signature : Name : Name : Address : Address :

1. Personal details:-

1. Name of the Pensioner : 2. Designation : 3. Date of retirement : 4. Address of the Pensioner :

Family Pensioners only:-

5. Relationship with deceased : 6. Name of the Family Pensioner :

2. Bank Details :-

1. Saving /Current Account No. : 2. Name of the Bank : 2. Name of the Branch :

3. (a) Certified that the Bank details (2 above) are correct. The account of pensioner and his/her signature given overleaf agrees with the specimen signature held in our records. (b) Any excess amount credited in the account of the pensioner and due/refundable to the PDA will be refunded immediately as and when called for by the PDA. Notwithstanding anything contained in this clause 3(b), the Bank and the PDA agree and understand that the obligation cost on the Bank by medium of this clause[3(b)], shall be subject to:- i. The rights conferred and the duties imposed on the Bank by Law and/or norm and/or regulations. Place : Signature of the Bank Manager Date : (Bank Accounts Seal)

• Note – Part 1 & 2 to be filled in by the pensioner and Part 3 by Bank.

MANDATE FORM

I, hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incompleteness or incorrectness of information given by me as above, I would not hold the user institution responsible. Dated ……………..

(Signature of Spouse) (Signature of the Beneficiary)

Certified that the particulars furnished above are Correct as per the record.

Bank Stamp (Signature of the Authorised officer )

Dated

1. Beneficiary Name

2. Beneficiary/Address &Telephone No.

3. Beneficiary Account No.

4. Account type ( Saving/Current for Cash Credit)

5. Nine digit code number of the Bank & branch appearing on the MICR Cheque issued by the bank (if available)

6. Bank Name

7. Branch Name & Address with Telephone No.

8. IFSC (Indian Financial Services Code)

9. Photo copy of the cancelled cheque to confirm correctness of IFSC code and Account No. given

PERSONAL IDENTIFICATION MARK OF SPOUSE OF

SRI/SMT ……………………………………… …….

SRI/SMT………………………………………………………..

Height……………………………………………………………

Identification Mark……………………………………………

Blood Group…………………………………………………….

SIGNATURE…………………………………………………….

Name of the employee

Signature of the employee

HR No.

LETTER OF UNDERTAKING Date: ……………..

To Under Secretary (STP), DoT, New Delhi/Pr.CCA/CCA ………………………………………………………..

(Strike out whichever is not applicable)

(Through O/o ……………..BSNL………………..)

Ref: (i) DoT letter No. 40-12/2004-Pen(T)(pt.) dated 17-05-2018 & (ii) BSNL C.O. letter No. 48-11/2017- Pen (B) dated 30-05-2018 Sir,

I, Shri ……………………… ………. , Desgn. …… , O/o …………………

hereby undertake that in case the court case(s) filed against the DoT order no. 40-12/2004- Pen

(T)(Pt.) dated 05.7.2017 are decided in favour of this DoT order, I shall refund the over-

paid amount on account of grant of an extra-increment on the post based promotion under the

Executive Promotion Policy(EPP) of BSNL.

Yours faithfully,

Sign............................................ Name……………………………. Designation………………….......

Office……………………………. ………………………………

Residence Address……………………… ………………………….

Mob. No……………….. Landline……………….

Annex-III

UNDERTAKING

In accordance with BSNL CO. ND 1 letter no 412-24/2011-Pers.I dtd 11.8.2011

I hereby undertake that I have not filed any Court Case i.r.o Adhoc Promotions

And Subsequent Regular Promotions.

I hereby undertake to Refund any excess payment that may be found to have been made as result

of outcomes of various Court Cases incorrect fixation of pay or any excess payment detected in the light

of discrepancies noticed subsequently including reduction of Pension /Pensioner benefits to the

Government either by adjustment against future payments due to me or otherwise.

Signature:……………………………………………

Name:……………………………………………......

Designation:………………………………………....