Form I

Form of application fox commutation of a fraction of s uperanuuaLion pension without medical F.li.anii­
nation when Applicant desires that ·the payment of the commuted value of pens1.on should be authori~1
through the pension payment order.

(To be submitted in duplicate at least three months before the date of re(ircment).

PART I

Subject : Conuuutatlon of Pension without medical examination,.

Sir,

I desire to cummut.e a fraction of my peos1on. Tbc necessary panticuliu"& are filrnish:il

bolow J~

l. Name in block letters.

2. Father's NaJEe (and. a.li.o hwband'~ Name in

the case of a fetllale Govt. Servan&.)

3. Designation & Token No.

4, Name of Officc/Deptt./ in which employed.

~. Date of Birth (by Chrlt;tian ern)

6. Date of retirement on su.perannuatlon or on

the expiry of eitcnsion in service granted
under FR 56 (d).

*7. Fraction of Superannuation p1;naiou proposed

to be commuted.

**8. Disbursing authoril.y froU:. which l'cnsion b to

be drawn after retirement.

a) i) Branch of tbe nominated nationalised

Bank with complete poi;tfll address.

ii) Bank Account No. to which monthly

pension is to be credited each ruonth.
 ..

b) Account Office of lhe DTG

Department/Office.

" ,
.. ':

Place:

Date:

Signature

.n

Present Post"! Address

.' .

Postal AJdcess
after retirement

Note :-

Tbe payment of commuted value of Pension shall be made through the cijsbursing authority from which
pension is to be drawn after retirement. lt is not open to an applicant to draw the commuted vaJue of
Pension from a disbursing authority other than the disbursing authority from which pension is to be
drawn.

The applicant should indicate to the fraction of tbe amount of montbly pension (Subject to a
maximum of one third thereof) which he/she desires to commute and not the amount tn rupees

0
Score out which is not applicable.

DPPP 28.11 .2005 ,,000 Coples

 Form 3
Details of Family

Nvme of 1.be Employee :

B. No.:

P. T. No.:

Da e of Birth ;

D41e of Appointment :

Details of the members of my fami ly•

s. Name of the Date of Relationship Initials Heads of

No members of birth with the Office
Famil,. Officer/employee
l 2 3 4 5

t.

....
~

3.

...
-·
6.

8.

9.

I hereby undertake to keep the above particularc; \Ip-to-date by notifying to the Head of Officer
:uij .l dditionor alternation .

Place :

n ted:

(Sjgnature of Employee)

· Fnmily for this purpose means :­

1a \\ ifc, in the case of a male employee.
lb Husband, in the case of a female employee.
(c Soos below twenty one years of age and unmarried daughters below twenty four years of age,
including such son or daaglltcr or daughter adopted legally before retirement.

_
.,, ...... .... ____
ote : Wife and husband shall include respectively Judicially dcparated wife and husband.
. _ _,,,....,,. __......___,...
·
-
-
~
 Form 5
hrticolars tft be rurni!'h~d ..=' ex-uiptoyee empi-O)~e'!
~ xe eUclMe for Pensloa.

I. "Name of the employee .

~. 1.) Date of birth :
b) Date of retirement :
3 •Two specimen signatures dt:ly attested
:·" be furnished in a. separate sheet

4. ••three copies of passport size joint

11i10tographs of the CJ·employee/employee
~ his/her wife/husband.

5. Two slips showing the particn.lars of

height and personal identification marks
duly attested by Gazetted Officer or
Officer of D.T.C.

6. Present Address :

7. Address after retirement :

8. Name of the Publio sector Bank Branch

tbrourh which tl-e ex·emplcvec:>!emplayee
wants to draw bis pension.

9. Details of the family in

Form 3

Place: ............ _.............................

Dated: .... _ ......................._ .......

Signature ...... ......... - ... ._ ····-··-··-· ­

Designation·--····- ...... ... ·-··· - ........ .

P.T. No .......... Name of Unit...... ..

*Two slips each bearing the left hand thumb and finger impressions duly attested, may be furnished by

-a person who is not literate enough to sign his name. If such an ex-employee/employee on account of
physical disability is unable to give the thumb and finger impressions of the right band where an ex-
employee/employee has lost both the hands, he may give his to impressions. Impressions should be
dully attested. ·

**Only two copies of Passport size photographs of self need be furnished.

i) If the ex-employee/employee of DTC is unmarried or a wjdower or widow.

*0 Where is not possible for an ex-employee/employee to submit a photograph with his wife/her
husband, be/she may submit separate photographs. The photographs shall be attested by the
Head of unit.
 UNDERTAKING

1, ...... ...... ... ...........................S/o W/o Sb .................... ..........................................................

Design..................... .............T. No... ......... ................hereby declare that I am availing Medical benefiu
from (Nnme of the Deptt.) ......................................................... ................................ .................. or
not availing medical benefits :­

A. Being dependent upon my children.

B. Being ex-serviceman.
c. Being employed in OTC/any other Department
D. Whether ex-serviceman cl drawing pension from
Military Department Rs....... ...... ...... ........... .

Signature of Pensioner
 The Deputy Managcr (Pension),
Delhi Transport Corporation,
t.P. Estate, New Dcl i:ii.

ft is requested that my pension may be paid to me through Syndicate Bank. I am ready

ro bear the .Bank charges, if any for the same. My Bank particulars are as under :­

1. Syndicate Bank Account No. (Saving)... ............................ .. ......... .

.., Full Address of Syndicate Bank Branch..... .. ..... ...............................

(Signature of Pensioner)
Name............. ................................ ..
De>ignatioo . . . . . .. . .. . .. . .. . .. . .. . .. . . .. .. .. . . ..
T. No..... ... .................................... ..

Address .. . .......... .................. ········ .. ..

Oated :­
 DELHI TRANSPORT CORPORATION
(Govt. of N.C.T. of Delhi)
l.P. Estate, New Delhi-110002
\JN:DE TAk.1"-'C:

I ................................................................... .......... S/o, W/o ..... ....................................................

Design ..................................................................... T. No .............................................................

Rio................................................................................................................... ............................... .
Unit ...................... ................................................... certify as under :­

(I) That I have drawn N.R.A. from M a nagement~ share of provident fund
Rs ...... ............ ....... ..... on .. ...................... .. .............. during my service period.

(II) That I have drawn Management's share of providentfund amounting to Rs . ..................... .

on ...................................... and total Gratuity amounting to Rs .................................... .
on .......... .......................... ................. .

(Ill) That I have not been in employment in any Government/Commercial Establishment after
my retirement till today and I shall inform as and when I join any employment.

(IV) That I have been in employment in ......... ............,. ..................... since ............... ....... ........ :
and drawing monthly salary of Rs . ..... .. ............................ .. . in total.

(V) That I am not drawing any kind of pension from any State/Central Govt. Department/
Military Department.

(VI) That I am drawing pension/family ·pension amounting to Rs .......................................... .

w.e.f...................................... f~om ..................................... (Name of the Deptt.).

(VII) That I have drawn a sum of Rs ......... ......... .. ................ Dated .... ...................... from RPFC.
In case I will draw any amount from RPFC in future , I shall deposit the same in Pension
Cell(HQ.)

(VIII) I am widow of Late Shri ...................................................... .. .... ... .. .. In case of re-marriage

I shall inform to Pension Cell (HQ.) immediately.

(IX) If any excess payment is paid to me, the same can be recovered from my Pension at any
time.
(X) That I shall abide by the C.C.S. Pension Rules, 1972, as amended from time to time.

DEPONENT
..
'
Certified that the above facts are true to the best of my knqwledge and belief and nothir:ig
has been cancelled. Certified on day of ....... ..... .. ...................... ... ...... ..... . .
'.

DEPONENT
Note · Please ensure that each and every column should be filled in typing only.
-:­
 OTC Hv11 OYr·l"S SllPl RA0<Nl 1;\TIO'\i PL\iSl()~~ TIU SI

(NOMl0< ;\ J ION FORM FOR CL!\I iv! ING Dl 11·,S)

I h..:1'1.:by nominmc the fo l lowing Person/ Persons for receiving lhe Pension f\rrenr/Cornmutat ion of l)e11sio11. other due-, uf· Pension clc. in the event• 1· my cle<ith.

.., N11 N.i111L· llr Nominee

- - -
Address of Nominee r Date of Birth ­ Relationship -with-1 - --- -- ----­
Total amount or share of accumulations in Specimen Sig1
1
Pensioner/Family Pension Arrear/dues clc. to be paid lo each Gt<.:h nominee
Pensioner nominee .

_,.._ - - - - -- ----­ - - -+-- - - - - - - - ~-

J
-------------

---------~---L ------t~
--1

-_
_ _]I I

-------- _____ _ __J

';1 -;tc the recent passport photograph of each nominee.

2 3 4 5 Signature of Pensioners/ ·amily Pension.

~amc:------- -- ---- -------- ------------------­

Design.------------------- I .\Jo. -----------­

Telephone No.------ ------ ·-----------------

DatcJ: