For

m1

OPTIONTOAVAI LBENEFI TSI NCASEOFDEATHORDI SCHARGEONI NVALIDATIONORDI SABILITYOF

GOVERNMENTSERVANT/SUBSCRI BERDURI NGSERVI CE
[
Seerule10)
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,herebyexerciseopt i
ont hati
nt heev entofmydi schargefr
om
servi
ceont heaccountofdi sabi
li
tyorr et
ir
ementf r
om ser viceonaccountofi nvalidati
onorDeat hdur
ing
servi
ce,benefit
sunderCCS( Pensi
on)Rules,1972orCCS( Ext
raordi
naryPensi
on)Rul es,1939ast hecasemay
be,maybepai dtomeormyf amil
y.
OR

I.
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.,herebyexerciseoptionthati
nt heeventofmydi schar
gef r
om
servi
ceont heaccountofdi sabi
li
tyorr eti
rementfrom ser v
iceonaccountofinvali
dationorDeathduring
servi
ce,benef i
ts.maybepai dt omeormyf amil
y,ast hecasemaybe,basedont heaccumul at
edpension
corpus inthe I ndivi
dualPensi on Accountundert he NationalPensi
on Syst
em i n accor
dance wit
ht he
CCS(Impl ement ati
onofNat ionalPensionSy stem)Rules,2021

Si
gnatur
eofGov ernmentser v
ant/Subscr i
ber
Name- .
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Designat
ion-.
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Off
iceinwhichempl oyed-.
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TelephoneNo. -
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Pl
aceanddat
e:

Thi
sopt
ionsupersedesanyot
heropt
ionmadebymeearl
i
er .
*Compl
etel
ystr
ikeoutthebenef
it
sforwhi
chopt
ioni
snotintendedt
obemade.

(
Tobef
il
ledi
nbyt
heHeadofOf
fi
ceoraut
hor
isedGazet
tedOf
fi
cer
)

Recei
vedt
heopt
iondat
ed.
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..underCCS(I
mpl
ement
ati
onofNat
ional
Pensi
onSy
stem)Rul
es,
2021

madebyShr i
/Smt./Kumari.
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Designat
ion..
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Off
ice..
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Entr
yofr ecei
ptofopt i
onhasbeenmadei npage.
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..Vol
ume.
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.ofSer
viceBook.

Signat
ure,
NameandDesi
gnat
ionofHeadofOf
fi
ceoraut
hor
izedGazett
edOf
fi
cerwi
th
seal

Dat
eofr
ecei
pt.
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.

Therecei
vingOf
fi
cerwil
lfi
l
ltheaboveinfor
mati
onandret
urnadul
ysignedcopyoft
hecomplet
eFormtot
he
Governmentser
vantwhoshoul dkeepi ti
nsafecust
odysothati
tmaycomei nt
othepossessi
onoft
he
benef
ici
ari
esint
heeventofhis/
herdeath/i
nval
i
dati
on.
 FORM 2
Detail
sofFamily
[
Seer ul
e10(3)
]

I
mpor
tant

1.Theor i
ginalFor m submi t
tedbyt heGov ernmentser vant/Subscr iberistober etained.Al laddit
ionsor
alterat
ionsar et obecommuni catedbyt heGov er nmentser vant/r
etir
edGov ernmentser v ant/Subscr iber
alongwi ththesuppor tingdocument sandt hechangesshal lber ecordedi nthisFor m undert hesignat ureof
HeadofOf fi
cei nCol7.NonewFor m willsubstitutet heor i
ginalForm.Howev er,ther et
iri
ngSubscr i
bershoul d
submi tthedet ailsoff ami lyaf reshatthet imeofr et i
rement.
2.Thedet ailsofspouse,al lchil
drenandpar ent s( whet hereligi
blef orfamilypensi onornot )anddi sabl ed
sibli
ngs( brothersandsi st ers)maybegi ven.
3.TheHeadofOf ficeshal lindicatethedat eofr ecei ptofcommuni cat i
onregar di
ngaddi ti
onoral t
erationi n
thef ami l
yi nt he' Remar ks'col umn.Thef actr egar dingdisabi l
it
yorchangeofmar italst atusofaf ami l
y
membershoul dal sobei ndi catedinthe'Remar ks' column.
4.Wi feandhusbandshal l includejudici
allysepar at edwi f
eandhusband.
5.Ther eti
redGov ernmentser vantshallattacht hedet ail
sofchangei nf amil
yst r
uct ureaf t
err eti
rementi nt he
proformapr escribedunderDept .ofP.&P. W.,O.M No.1( 23)-P.&P.W/ 91-E,datedt he4t hNov ember,1992.
6.Copi esofbi r t
hcer tifi
cat est obeat tached.Copi esofanyot herrelevantcertif
icates,ifav ail
able,shoul dbe
attached.
Nameoft he
Gov ernment
servant/ Designation Nat i
onal i
ty
Subscr i
ber

Det
ail
soff
ami
lymember
s:

S. Relati
onship
N. withGov t.
servant/ Dated
r
eti
r ed signatur
e
Name(Pleasesee Dat
eofbir
th Aadhaarno.
" Mari
tal Remar
k ofHeadof
not
esbel
owbef or
e DD/
MM/ YYY (opt
ional
) Gov er
nment st
atus s
servant Off
ice
fi
ll
i
ng) Y)
/Subscr i
ber

1.

2.

3.

4.

5.

6.

Iher
ebyunder
taket
okeept
heabov
epar
ti
cul
arsupt
odat
ebynot
if
yingt
otheHeadofOf
fi
ceanyaddi
ti
onor
al
ter
ati
on.
E-
mail:
(Opti
onal) Pl
ace:
Mobil
e:(Opti
onal) Dat
e (
Signat
ure)

*Pr
ovi
dingAadhaarNo.isopti
onal
.Howev er
,ifi
tisprovi
ded,consentt
olinkitt
oBankAccountandal
sof
or
aut
hent
icat
ionofident
it
yfrom UI
DAIforpensionrel
atedpurposeonly,
ispresumed.