Nt.
- I4
FORM-1
NOIIIIIATIOI{ FOR RBTIREMENT GRATUITTIDEATH GRATT'ITY
{See Rute 53(1} of CSS {Penslon} Rules, 19?2}
When tl.e Govemment Servant has a famllv, and wishes to nominate one
member, or more that one member, tleereof.
hereby nominate the
person/persons mentioned below, who is/are member{s) of my family, and confer
on l:.im/!l.er /them the right to receive, to the ext€nt specified below, any gratuity the
payment of whlch may be authotized by the Central Government in the event of my
death while in service and the right to receive on my death, to the extent specified
below, any gratuity which having become admissible to me on retirement may
remain unpaid at my death-
Orlgtnal nonlnoo (s| Altertratlve nomlneelal
Namc (sl and address lesl of Relatlon- Age Amount Name, address, Amount
nomlnee(sl shtp with or share relatlorshlp and age of or share
Govt. of the person or per3ons, lf of
a€rvant gratuity ary, to whon tbe rlght gratutty
payeble conferred on the payable
to nomlnee shall pass ln to
each* the event of tho nomlaee eachs
pre-deceaslEgtbe Govt.
selatrt or tbe rromhee
dytng after the death of
the Govemment servaDt
but before recolwlng
Deyn'ert of (ratulty
t1) (21 (3) (41 (s) (6)
NOTE:-
(i) The Government Servant shall draw lines across the blank space below the last entry
to prevent the insertion of any name after he/she has signed.
(ii) Strike out which is not applicable.
* This column should be lilled in so as to cover the whole amount of the gratuity.
** The amount/share of the gratuity shown in this column should cover the whole
amount/share payabre to the original nominee(s).
contd...2/_
N-Z
This nomination supersedes the nomination rnade by me earlier on
which stands caneelled.
Dated this day of . 2A _at
Signature of Govemment Servant.
Witnesses to signature:
1.
2.
lTo be flllcd by tbc llcad of Ofeol
Nomination by: Signature of the Head of Offrce:
Designation: Date:
OIIice: Designation:
****l****t*********t***********t*****rr***!r****t***it****t!t*****
N- 3
FORM-3
DETAILS OF FAMILY
{Required vlde Rule 54 {121 of CCS {Penslon} Rules' 1972}
Name of the Government Servant :
Designation :
Date of birth :
Details of members of my family* as on :
sl. l{ame of the }lembers of Date of Relatlonshlp Inttlals of Re'narks
No. fatnlly* Birth crlth the the Head
oflicer of offrce
(1t (21 (3) ftl t5l {6)
I hereby undertake to keep the above particulars up-to-date by notifying the
Head of Office anv addition of alteration.
Place: Signature of Government Servant.
Date:
&
" Family for this purpose means family as defined in Clause (b) of sub-rule (14)
of Rule 54 of the CCS (Pension) Rule, 1972.
NOTE: Wife and husband shall include respectively judicially separated wife and
husband.
Deflnltlon of 'Famllv' for famlly perrslon
lClause lbl of Rule 541141 of CCS lpenslonl Rules. 19721
1. Wife in the case of a male Government servant, or husband in the case of a female
government servant.
2. A judicially separated wife or husband, such separation not being granted on the
ground of adultery and the person surviving was not held guilty of committing
adultery.
3, Son who has not attained the age of twenty-five years and unmarried daughter who
has not attained the age of twenty-five years, including such son and daughter
adopted legally before retirement.
N- 4-
FORM-8
NOMIITATION F1OR BEITEFITS UNDER THE CEITTRAL GOVER]TMENT
EMPLOYEES' GROI'P INSURANCE SCHEME. 1980
{Required vide paras 19.1 to 19.9 of the scheme)
When the Government servant has a familv, and wishes to nominate one
member, gr more than one member, thereof,
hereby nominate the
persons{s) mentioned below, who is/are member{$} of my family, and confer on
him/her/them the right to receive, to the extent specifled below any amount that
may be sanctioned by the Central Government under the Central Government
Employees' Group Insurance Scheme, 1980, in the event of my deattr while in
service, or which having become payable on my attaining the age of
superannuation, may remain unpaid at my death,
l{ame (sf and address lesf of Relatlon- Age Share of Contlngen- Nqme, address
nomlnee(s| shlp wlth amount cles dn the and relatlonshlp
Govt. to be happening of the person, lf
servant patd to of whlch any, to whom
each* the the rtght of the
nonlnation nomlnee shall
shall pass ln the event
become of hts/her/thetr
lnva[d predeceaslng the
Governmertt
aenrant.
(1) QI {31 {41 (5) (6)
Note:- The Government servant shall draw lines across he blank space below the
last entry to prevent the insertion of any name after he/she has signed.
* This column should filled in so as to cover the whole amount of the gratuity.
Contd...2/-
N-5
-2-
Dated this dayof 2o- at
Signature of Government eervant,
Witnes€es to eignature:
1.
2.
Nomination by: Signature of Head of Ofliee:
Designation: Date:
Office: Designation:
********t*******ttt***********i!:t**************************
N-6
DETAILS OF FAItrILY FOR LTC/TA
{For deflnltlon of (FAMILY'. see overleafl
sl. Name Relatlonehlp If I{OT ltvtng wtth Govt.
l{o. Eenrant, resldentlal
addregs
Certified that the above information is true and correct to the best of my
knowledge. I hereby undertake to deep the above details updated and also to inform
the offrce whenever any of the members of my family mentioned above cease to be
covered under the previsions of the relevant rules for purposes of LTC/TA.
Signature
Place: New Delhi
Name
Date:
Designation
FOR OFTICIAL USE OITLY
ACCEPTED
Receivedon: Signature of Controlling Oflicer:
Diary No: Name:
(Olflce Sealf Designation:
' Contd...2/-
N-7
-2-
DEFINITIOI{ OF FAMILY AJTD LTC/TA
{ItilDER RttLE 4 {Dl OF CCs fl,T'ct RnLEs. tga8 Ar{D sR 2t8t
For wc/TA purpose, Tanlly'of the Govt. servant incrudes the following:
1. wife or Husband, as the case may be, residing with the Government servurnt.
The following membere of the family are also covered rF they are residins with
- are whollv dependent on the Govt, servant.
A![I]
(lilholly Dependent'means whose income from a-ll sourcee, including peneion
(inclusive of ternpora4r increase in pension and pension equivaleni of ncRG
benelits) and stipend and scholarships, if any does not exceed R;. 3,SOO/- p.m.l
(The condition "Residing with" has been waived for purpose of LTC for spouse
and members of family.)
2. Legitimate children, and stepchildren;
An adopted child shall be considered to be a legitimate child, if, under tl.e
personal law of ttre Government servant, adoption is legally recognized as conferring
on it the status of a natural child (TA Rules).
children' include children taken as wards by the Government servant under
the oGuardians and wards Act, 1980, provided such a ward is treated as a member
of the family' and the Govt. servant, through a special will, has given such a ward
the same status as a natural child {LTC Rules).
children' include major sons, married daughters including widowed
daughters, so long as they are residing with and wholly dependenf upon the
Government Servant.
Married daughters are covered only in exceptional circumstance, such as where
she has been divorced, abandoned or separated from the husband, and is
financially wholly dependent on parents,
3. Parents, Step-motJrer;
4. Minor brothers:
5' unmarried or widowed sisters, provided their father is either not alive or is
himself wholly dependent on the Government Servant.
****************************************************
N- I
DEFINITION OF FAMILY FOR GPF/CGEGIS
{Rule 2 {1) of GPF (CSl Rules, 196O}
{Para 19.3 of CGEGI Scheme, 198O}
1. In the case of a ma-le subscriber, the wife or wives, parents, children, minor
brother, unmarried sisters. Deceased son's widow and children and where no
parents of the subscriber is alivb, a paternal grandparent.
If a subscriber proves that his wife has been judicially separated from him or
has ceased, under the customarJr law of the community to which she belongs, to be
entitled to maintenance, she shall henceforth be deemed to be no longer a member
of ttre subscriber's family unless the subscriber subsequentiy intimates in writing
that she shall continue to be so regarded.
2. In the case of a female subscriber, the husband, parents, children, minor
brothers, unmarried sisters, deceased son's widow and children and where no
parents of the subscriber is alive, a paternal grandparent.
If a
subscriber by notice in writing expresses her desire to exclude her
husband from her family, the husband shall henceforth be deemed to be no longer
a member of the subscriber's family unless the subscriber subsequently cancels-
such notice in writing.
NOTE: 'Child' means a legitimate child and includes an adopted child, where
adoption is recognized by the personal law governing the subscriber. Such a child
will be excluded from the family of the natural father. A ward under the Guardian
and Wards Act,189O, who lives with the Government servant and is treated as a
member of the family and to whom the Govt. servant has, through a special will,
given the same status as that of a natural born child will also be treated as Child'
for the purpose of GPF/CGEGIS.
N- 3
Account No.
I, hereby, nominate the person(s)
mentioned below, who is / are member (s) non-members of my family as defined in Rule 2 of
the General Provident Fund-{central services) Rules, 1960, to receive the amount t}rat may
stand to rny credit in the Fund as indicated below, in the event of my death before that
amourt has become payable, or having become has not been paid.
Itamelsl atd full Relatlon Age Share Contingen- Ifame, addreea if the
addresa lesf of -8hlp payable clea on th€ aad relationshlp nomlaee
nonlneelel with the to each happentng of tbe pereon{el, fs not a
aubacrl- aomlnee of whlch the lf any, to whom rae mber of
bet nomlnatlon the right of the tbo ftntly
wlll become nomlnee eha[ sa
lnvalld pass in the provtded
event of ln Rule 2,
hls/her/thetr lndlcate
Pre-deceaslrrg the
the subscrlbor feasous
Dated this day of 20 at
Signature of the Subscriber:
Name in Block letters:
Designation:
Witnesses to signature:
l.
2.
lCounterslgned by the Head of offlce as per para 19.9 of the Scheme.f
Nomination by: Signature of Head of Office:
Designation: Designation:
Oflice:
Date: (Seal)
