Pension Form Aand B

FORM A
[See Rule 5]

Pension Disbursing Authority/Head of Office
(Name of Bank/Treasury/Post Office/Accounts Officer, etc.)
Place...........................

    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) Rules, 1983.

Name and address of the nominee	Relationship with the pensioner	If nominee is minor		Name and address of other nominee in case the nominee under column (1) predeceases the pensioner	Relationship with pensioner	Date of birth if the other nominee is minor	Name and address of person who may receive the pension during the other nominee's minority	Contingency on happening of which nomination shall become invalid
		Date of birth	Name and address of person who may receive the said pension during the nominee's minority
1	2	3	4	5	6	7	8	9

Place : .............................................. Date  : .............................................. Witness : Signature : Name & address : Signature of Pension Disbursing Authority/Head of Office. Acknowledgement to be sent by the Pension Disbursing Authority/ Head of Office.		Signature (or thumb-impression if illiterate) and name of pensioner. Address :
Certified that application/nomination has been received from ....................................................... (name of pensioner) whose address is ..................................
Place : Date  :		Signature of Pension Disbursing Authority Bank/ Treasury/ Post Office/ Accounts Officer/ Head of Office. Full Address :

FORM B

[See Rule 5(5)]

Pension Disbursing Authority/Head of Office
(Name of Bank/Treasury/Post Office/Accounts Officer, etc.)
Place...........................

    I,.........................................(Name of Pensioner in Capital letters) hereby make the following alternative nomination in cancellation of the previous nomination made on ....................................................... under Rule 5 of the Payment of Arrears of Pension (Nomination) Rules, 1983.

Name and address of the nominee	Relationship with the pensioner	If nominee is minor		Name and address of other nominee in case the nominee under column (1) predeceases the pensioner	Relationship with pensioner	Date of birth if the other nominee is minor	Name and address of person who may receive the pension during the other nominee's minority	Contingency on happening of which nomination shall become invalid
		Date of birth	Name and address of person who may receive the said pension during the nominee's minority
1	2	3	4	5	6	7	8	9

Place : .............................................. Date  : .............................................. Witness : Signature : Name & address :		Signature (or thumb-impression if illiterate) and name of pensioner. Address : Signature of Pension Disbursing Authority. Date Stamp.
Certified that application/nomination (From B) has been received from ................(name of pensioner) whose address is ........ Form A has been cancelled and returned to him.
Place : Date  :		Signature of Pension Disbursing Authority P.O./Bank/Treasury with full address ...........

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