Application Form
PAYMENT OF RETIREMENT BENEFIT
PART - I
1 Personal # Paste passport
size photograph
2
a) Name of Beneficiary
b) CNIC No. - -
c) Father / Husband Name
d) Last Position held
alongwith BPS
e) Name of Department
f) Station/Place of last Posting
dd mm yyyy
3 Date of Birth - -
4 Date of Appointment - -
5
Date of Retirment OR removal from - -
service on account of
a) Superannuation / b) Dismissal from Service c) Removal
Qualifying service
d) Termination e) Resignation (Tick the relevant box)
6 Regular Contributions to
a) Group Insurance From To
b) RB&DC From To
c) Missing period in case of
leave without pay etc. i From To
ii From To
iii From To
7 Address
a) Present/Postal
b) Permenant
c) Contact No.
Signature or Thumb Impression
of Beneficiary
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Application Form
PAYMENT OF RETIREMENT BENEFIT
8 Bank Detail
a) Name of Bank b) Bank Code
c) Title of Account
d) Type of Account (i.e. PLS, Saving, Current)
d) Account No
Signature of Branch Manager Stamp with Branch Code
PART-II
CERTIFICATE
1 Certified that the information contained above in respect of Mr/Miss/Mrs ________________________________ is correct
and according to our record.
2 Certified that the above named employee was neither a contingency/work charged/adhoc/contract employee nor a
deputationist from any Provincial Government or Federal Government and he/she was a regular contributor of RB&DC &
Group Insurance Funds
3 Certified that the claim has been submitted for the first time and had never been sent previously from any office of this
department.
4 Certified that this department reserve the right to refund the amount of all grants sanctioned under RB&DC scheme, in case
of fake/fictitious documents / information in respect of the above named employee.
Seal and Signature
Dated_______________ Head of the office
Forwarded to the Board of Retirement Benefit & Death Compensation Fund, Finance Department Peshawar for grant
of retirement benefit
Dated_______________ Seal and Signature
Head of the Department
Required documents & Instructions for submission of Application Form
a The application form must be countersinged by the concerned Head Administrative Department / Head of Attached Department
b Attested Photocopy of Retirement Order / Notification
c One Photograph of the beneficiary
d Attested photocopy of CNIC of beneficiary
e Leave account duly signed by the DDO, in case of Gazzetted be issued by the AG/DCA/DAO/AAO(s)
f Computerized pay slip showing RB&DC deduction, Pay stoppage certificate duly signed by the office of the DDO/AG/DCA/DAO/AAO(s)
g Attested Photo copy of first and 2nd page of S/Book, In case of Gazzetted a Service Certificate be issued by the AG/DCA/DAO/AAO(s)
h A copy of the Medical Board proceedings duly attested by the Head of Department.
i The attached docments should be marked as Annexure A, B, C etc
j Forward application form with covering Letter to:
Project Manager (RB&DC), 1st Floor Directorate of Treasuries & Accounts, Khyber Pakhtunkhwa
Peshawar
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Application Form
Payment of Death Compensation
PART - I
1 Personal Information Paste passport
size photograph
a) Personal #
b) Name of the Deceased
employee
c) CNIC No. - -
d) Father / Husband's Name
e) Last Position held
alongwith BPS
f) Name of Parent Department
g) Station / place of last posting
dd mm yyyy
h) Date of Birth - -
i) Date of Appointment - -
J) Date of death - -
2 Whether regular contributor to
a) Group Insurance From To
b) RB&DC From To
c) Missing period in case of
leave without pay etc. i From To
ii From To
iii From To
PART-II
3 Nomination of beneficiary
a) CNIC No. of Spouse (in case - -
of married employee)
Name of benficiary (s) (nominated or otherwise) __________________________________________________________________
b)
S Relationship %age of
Name Father's Name CNIC No. Date of Birth
No with the Share
1
2
3
4
5
6
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Application Form
4 Address of Beneficiary
Present/Postal
Permenant
Contact No.
Signature or Thumb Impression
of Beneficiary
5 Bank Detail
a) Name of Bank b) Bank Code
c) Title of Account
d) Type of Account (i.e. PLS, Saving, Current)
d) Account No
Signature of Branch Manager Stamp with Branch Code
PART-III
CERTIFICATES BY THE HEAD OF DEPARTMENT
1 The information contained above in respect of Mr/Miss/Mrs __________________________________________
_____________________________ is correct according to our record.
2 The above named employee was neither a Contingent Paid / Work Charged / Adhoc / Contract employee etc nor a
deputationist from any Provincial / local Government and he is/was a regular contributor of RB&DC & GI Funds. Further he
/she was neither dismissed nor removed from service (in case of a deputationist from one Federal Government Department
to another, the case will be prepared by his/her paraent Department)
3 Certified that the employee died during the continuance of service after retirement.
4
The particular of nominee(s) and sum assuered etc. of deceased employee mentioned in Part - I & II above are correct and
there is no other nominee(s) as per record of this office. In case, particulars of nominee(s) given in Part - I & II found
incorrect at later stage by any forum, our department will be responsibe for refund of sanctioned amount(s) to RB&DC Fund.
5 Certified that the claim has been submitted for the first time and had never been sent previously from any office of this
department.
6 The above named employee was not uniform employee of Armed forces at the time of death.
Dated _____________________ Seal and Signature
Head of the office
Forwarded to the Board of Retirement Benefit & Death Compensation Fund, Finance Department Peshawar for grant
of retirement benefit
Dated _____________________ Seal and Signature
Head of the Department
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Application Form
Required documents & Instructions for submission of Application Form
a) Last pay certificate/computerized pay slip duly countersigned by head of department showing personal No. allotted by
the Accountant General, Khyber Pakhtunkhwa / District Account Officer
b) First and second page of service book/PPO/statement of service in case of gazetted employee .
c) CNIC in respect of the aforesaid deceased employee and the prospective beneficiaries and in case of any minor
beneficiary, B-Form (Both sides of CNIC must be copied on A-4 sixe paper).
d) Death certificate issued by Union Council / Union Committee/Municipal Committee duly attested.
e) Death Notification/order under which the name of the said employee was struck off strength.
f) Nomination form for pertaining to Retirement Benefit & Death Compensation Fund filled in the employee during service
g) List of dependent family members i.e. wife/wives, natural son(s), father, mother, minor brothers and
unmarried/divorced/widowed sisters/daughters. The list should indicate name, CNIC No. relationship, age, marital status,
profession, monthly income, present mailing address and contact number(s).
h) Wholly dependency certificate (other than spouse) issued by the Head of the Department/Officer authorized by the
department (Authority letter must be attached).
i) Envelope containing four copies of photographs duly attested in respect of each beneficiary bearing the name of the
person on the reverse of three photos and one on the face. In case of purdah observing ladies, photographs will not be
required, A certificate that she is Purdah observing lady must be attached.
j) Four signatures/right and left thumb impressions on separate sheets (four on each sheet) of each beneficiary /
dependents duly attested by class-1 Gazetted Officer.
k) In case of female prospective beneficiaries one widow/non-marriage/re-marriage certificate
l) Forward application form with covering Letter to:
Project Manager (RB&DC), 1st Floor Directorate of Treasuries & Accounts, Khyber Pakhtunkhwa
Peshawar
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