FORM-A

PART-I
[Rule 10(2).]
I, ……………………………………….. desire to commute a portion of my
original pension of Rs. …………………… a month. I certify that I have correctly
answered the questions below:

Signature :
Dated, the
Designation :
Place
Address :

1. How much of your pension do you wish

to commute?
2. Have you a wife/husband?
3. How many members are there in your
family (with ages and sex)
4. What was your monthly income from all
sources during the past year?
5. Do you suffer from any complaint likely
to shorten life? If so, state its nature.
6. What is the class of your pension
(compensation/invalid/superannuation/reti
ring/compassionate)
7. What is the date and year of your birth?
8. From what Treasury/Bank do you draw
your pension?
9. What is the number of your present
Pension Payment Order issued by the
Accountant General, West Bengal?
10. (i) Have you commuted any portion of
your pension previously? If so, please
give details.

(ii) Have you applied for commutation of

your pension previously? If so, please
give details
11. What portion of the pension commuted by
you represent your original pension and
relief in pension if any?
12. Whether the pension has been sanctioned
under the old Pension rules or the new
Pension Rules?
 FORM A
PART-II
[Rule 20(1) (a)]

No. ………………… Date:-.

ACKNOWLEDGEMENT

Received from Shri/Smt………………………………………. application in in

PART-I of Form-A for commutation of a portion of pension after medical examination.

Date:-

Place:-
Signature of the Competent Authority
 FORM-A
PART-III
[Rule 20(1) (b)]

No………………….. Date:

Forwarded to the Audit Officer (here indicate the address and designation)
……………………………………………… with the remarks that the particular
furnished by the applicant in Part-I have been verified and are correct and the applicant is
eligible to get a portion of his pension commuted after medical examination.

2. It is requested that Part-IV of Form A may be completed and returned to this

office as early as possible.

Date:-

Place:-
Signature of the Competent Authority
 FORM-A
PART-IV
[Rule 20(2)]

Forwarded to ………………….....................................................………………………………………..

2. Subject to the Medical Authority’s/Medical Board’s recommending commutation, the lump sum
payable will be as stated below :

Sum payable, if the commutation becomes absolute before the applicant’s next birthday which
i) falls on ..………….....................................................................................
On the basis of normal age, ie, ……...….years Rs ………………………..
1. Year, ie,…………………..years. Rs.
2. Year, ie,…………………..years. Rs.
3. Year, ie,…………………..years. Rs.
4. Year, ie,…………………..years. Rs.
5. Year, ie,…………………..years. Rs.

ii) Sum payable, if the commutation becomes absolute after the applicant’s next birthday but one.
On the basis of normal age, ie, ……………..years Rs ……………………..
1. Year, ie,…………………..years. Rs.
2. Year, ie,…………………..years. Rs.
3. Year, ie,…………………..years. Rs.
4. Year, ie,…………………..years. Rs.
5. Year, ie,…………………..years. Rs.
3 The sum payable will be a charge on
Central revenues Rs.
The Govt. of West Bengal Rs.

Station :

Signature and designation of Audit

Date : Officer

1. Name and address of the pensioner :

2. Amount of the original pension :

3. Amount on which value is reported :
4. Class of pension :
5. Date of retirement :
 FORM A
PART V(I)
[ Rule 20 (3) ]

( If the applicant desires to commute a sum not exceeding Rs. 25 )

No……………….
Place:- Date:-

MEMORANDUM

With reference to his application, dated ………regarding commutation of a portion of his

pension, Sri/Smt.………………………………… is informed that Government is prepared to
consider the question of allowing him to commute Rs…………….. out of his original monthly
superannuation pension of Rs…………….. for a lump sum of Rs…………………. Provided
commutation can be sanctioned to take effect from a date prior to his next birth day falling on
……………….. after setting all the preliminaries connected with the sanction. He is accordingly
requested to sate whether he is willing to accept the above lump payment and if so to submit a
medical certificate in the prescribed form from Dr……………… ……… ……………. the Chief
Medical Officer of Health, ……………………….. / Sub-Divisional Medical Officer
…………………… as to the average expectation of his life and bring with him at the time of
examination the enclosed Form-B (Part-I) with particulars required therein except for the
signature. The medical examination fee of Rs. 16.00 should be paid to the aforesaid Surgeon.

2. He is also informed that the existing table on the basis of which the sum has been
calculated is subject to alteration at any time without notice and consequently the sum calculated
is also liable to revision.

3. He is further informed that unless the medical certificate is produced within three weeks
from the date of receipt of this order his case will be closed.

4. An acknowledgement of the receipt of this order is requested within seven days.

Signature of the Competent

Authority
To
The……………………………………
…………………………………………
………………………………………..
(Name and address of the applicant)

No……………………………………….

Copy with a copy of Form B (Part-II) forwarded to Dr…………….……....

...........................……………………... /CMOH…...…....................................
/ Sub Divisional Medical Officer…………………………... for information with the
request hat after obtaining from the applicant a statement in Part I of
form B (which must be signed in his presence) he shall subject him to a
strict examination and enter the results of his examination in Part-II of
Form B. He is also requested to record his opinion as to the accuracy
with which the pensioner has answered the question in Part I regarding
his medical history and habits and complete the certificate contained at
the end of Part-II of Form B. the applicant’s signature or impressions of
the thumb of his left hand should also be obtained on the certificate.

(Signature of the
Competent Authority)
 FORM A
PART V(2)
[ Rule 20 (3) ]

( If the applicant desires to commute a sum exceeding Rs. 25 )

No….......................…………….

Place:- Date:-.

MEMORANDUM
With reference to his application, dated ………regarding commutation of a portion of
his pension, Sri/Smt.………………………………… is informed that Government is
prepared to consider the question of allowing him to commute Rs…………….. out of his
original monthly pension of Rs…………….. for a lump of Rs…………………. provided
that commutation becomes absolute before the next day of his birth falling on
……………….. He is accordingly requested to state whether he is willing to accept the
above lump payment and if so to submit a medical certificate in the prescribed form from the
Medical Board as to the average expectation of his life and bring with him at the time of
examination the enclosed Form-B (Part-I) with particulars required therein completed except
for the signature.

2. H is also requested to deposit a fee of Rs. 16 in to a Govt. Treasury under the

“Head 080- Medical –A. Allopathy-VI-Other receipt-Other items” and to make over the
receipt of the Fee to the Board before the examination.

3. He is also informed that the existing table on the basis of which the sum has been
calculated is subject to alteration at any time without notice and consequently the sum
calculated is also liable to revision.

4. The date, time & place o the meeting of the Board will be communicated direct by
the ……………………………………………..

5..An acknowledgement of the receipt of this order is requested within seven days.

Signature of the
Competent Authority
 To
Shri/Smt………………………...........
……………………………………….
……………………………………….
(Name and address of the applicant)

No……………………………………….

Copy with copies of Form B (Part-II & III) forwarded to

………………………………… for information and necessary action with the request that
the Board may instructed that after obtaining from the applicant a statement in Part I of form
B (which must be signed in his presence) It shall subject the pensioner to a strict examination
in the light of the facts stated in the medical statement and enter the results of its
examination in Part-II of Form B. The Board may also be requested to record its opinion as
to the accuracy with which the pensioner has answered the question in Part I of Form-B
regarding his medical history and habits and complete the certificate in Part-III of Form B.
The applicant’s signature or impressions of the thumb of his left hand should be obtained on
the certificate. The date, time, and place o the meeting of the Board may also be
communicated to the applicant. The date of examination to be fixed may be any date
convenient to the Board within three months from the date of this Memorandum. The
present address of the applicant is noted above.

(Signature of the
Competent Authority)

Note:-The medical Board in the district will consist of Chief Medical Officer of Health and
the district Medical Officer. In case The chief Medical Officer of Health is not
available, It may consist of the District Medical Officer and Nominee of the Chief
Medical Officer of Health, who should be a member of the West Bengal Health
Service.

Date:-

Place:- Signature of the

Competent Authority
 FORM –B
[Rule 23 (1)]
Medical Examination by the ………………...................………………………………………
.................................................................(here enter the medical authority)

PART-I

Statement by the applicant for commutation of a portion of his pension. The

applicant must complete the statement prior to his examination by the
…………………………… (here enter the medical authority) and must sign the declaration
appended thereto in the presence of that authority.

1. State your name in full ( in block letters) :

2. State place of birth :
3. State your age & date of birth :
Furnish the following particulars
4. :
concerning your family
Number of brothers
Father’s age at Number of brothers
Father’s age if living dead, their ages at
death and cause of living, their ages and
and state of health death and cause of
death state of health
death

Mother’s age if Mother’s age at Number of sisters Number of sisters

living and state of death and cause of living, their ages and dead, their ages at
health death state of health death and cause of
death

5. Have any of your near relations suffered :

from tuberculosis ( consumption, scrofula),
cancer, asthma, fits, epilepsy, insanity or
any other nervous disease?
6. Have you ever :
a. had small pox, intermittent or any :
other fever, enlargement or
suppuration of glands, spitting of
blood, asthma, inflammation of lungs,
pleurisy, heart disease, fainting
attacks, rheumatism, appendicitis,
epilepsy, insanity or other nervous
disease, discharge from or other
disease of the ear, syphilis,
gonorrhoea, or
b. had any other disease or injury which :
required confinement to bed or
medical or surgical treatment, or
c. undergone any surgical operation? :
7. Have you any rupture. ? :
8 Have you varicocele, varicose veins or :
piles ?
9 Is your vision in each eye good ? :
10 Is your hearing in each ear good ? :
11 Have you any congenital or acquired :
malformation defect or deformity ?
12 When were you last vaccinated ? :
13 Is there any further matter concerning your :
health not covered by the above questions
which should be communicated to the
medical authority ?
14 Have you ever been granted leave on :
medical certificate ? If so, state periods of
leave and nature of illness.
15 Have any application for insurance on your :
life ever been declined or accepted at an
increased premium ?
16 a Have you ever been told that you had :
albumen or sugar in the urine ?
b Do you rise at night to urinate ? :
c Are you now or have you ever been on :
special diet for your health ?
d Has there been any marked increase or :
decrease in your weight wighin the past
three years ? If so, how much ?
17 Have you been under the treatment of :
any doctor within the last three months
? If so, for what illness ?
 Declaration by Application

(To be signed in the presence of the medical authority)

I declare all the above answers to be, to the best of my belief, true and correct.

I will fully reveal to the medical authority all circumstances within my knowledge
that concern my health and fitness.

I am fully aware that by willfully making a false statement or concealing a

relevant fact I shall incur the risk of losing the commutation I have applied for and of
having my pension withheld or withdrawn under Article 351 of the Civil Service
Regulations.

Signed in presence of the ……………………………………….

(Applicant’s signature)

(Signature and designation

of medical authority)
 FORM –B
PART-II
[Rule 23 (1)]
(To be filled by the examining medical authority)

1. Apparent age :
2. Height :
3. Weight :
4. Girth of abdomen at level of umbilious :
5. Pulse rate - a) Sitting :
b) Standing :
c) What is the character of pulse? :
6. What is the condition of arteries? :
7. Blood pressure - a) Systolic :
b) Diastolic :
8. Is there any evidence of diseases of the a) Heart :
main organ? b) Lungs :
c) Liver :
d) Spleen :
e) ……….. :
9. Does chemical examination of urine (i) albumen :
show. State specific gravity. (ii) sugar :
10. Has the applicant a rupture? If so, the kind and if :
reducible
11. Describe any scars or identifying marks :
12. Any additional information :

I have carefully examined………..................................................................………

and am of opinion that –

Either he/she is/is not in good bodily health and has the prospect of an/is not a fit
subject for average duration of life/commutation (in case of an impaired life which is yet
considered a fit subject or commutation) “as ……………………………… is suffering
from ……………….. his /her age for the purpose of commutation, i.e., his/her age on
next birthday should be taken to be ………………… years more that his/her actual age”

Station:-

Date: (Signature and Designation of

examination medical authority)

(Signature or
thumb impression of the left hand
of the applicant.)
 FORM B
PART-III
[Rule 23(2)]

We have carefully examined ……………………….. and are of opinion that Either

he/she is /is not in good bodily health and has the prospect of an average duration of life /is

not a fit subject for commutation or (in the case of an impaired life which is yet considered a

fit subject for commutation) “as …………………… is suffering from ………………………

his/her age for the purpose of commutation i.e., his/her age next birthday should be taken to

be years more than his/her actual age”.

Station:-

Date: (Signature and Designation of

examination medical authority)

(Signature or
thumb impression of the left hand
of the applicant.)
 FORM-C
(To be submitted in duplicate
PART I
[Rule 14(1)(a)]
Form of Application for Commutation of Pension without
Medical Examination
I furnish below the relevant particulars and request that I may be permitted to
commute a portion of my pension as indicated below
1. Name (in Block letter) :
2. Date of birth :
3. Date of superannuation on attaining the age of 58 :
years(or 60 years in the case of Group D
employees): (60 years)
4. Designation of the post held at the time of :
superannuation and the name of the
Department/Office;
5. Amount of pension sanctioned and whether it is :
provisional or final:
6. Class of pension as defined in the West Bengal :
Services(Death-cum-Retirement Benefit) Rules,
1971:
7. Name of Treasury of Bank and Account Number :
from which pension is being drawn:
8. Name of Treasury of Bank through which he :
commuted value is desired to be paid, if payment is
not desired through the Accounts Officer who
authorized the pension:
9. Designation of the Accounts Officer and the :
Number and date of the Pension Payment Order, if
issued:
10. Amount (in whole rupees)of pension and portion of :
pension proposed to be commuted :
11. Particulars of any application for commutation of :
pension made previously and whether appeared
before any Medical authority or not.

Signature :
Full address :
Date:-
No. :
 PART-II
No……………………….

Forwarded to the Accountant General ,West Bengal for authorizing the payment
of the commuted value . The receipt of Part-I of Form C has been acknowledged in Part –
III which has been forwarded separately the application on…………………

Date

Signature of the
Competent Authority

PART III
Acknowledgement

Received from Shri……………......................................................………………..

retired on ...................……(Designation)….....................................................………… an
application for commutation of pension without medical examination.

Date

Signature of the
Competent Authority