FORM 6

[See rules 57(1), 58, 59 and 60, 62, 80]

Particulars to be obtained by the Head of Office from the retiring/retired Government Servant

Photograph(s)

1. Detail of Government servant:

Name Designation/ Rank
Date of birth Date of retirement
Ministry/Department/Office PAN No.
Aadhaar No.*(voluntary) Nationality
2. Address after retirement for future correspondence:
Flat/House No./Bldg. Name Street/Locality
Village & Post Office/Block City & District
State Pin Code
Telephone No. (If any) Mobile No.
E-mail ID
3. Details of Bank through which Pension is to be drawn:
Type of A/c Single Joint with Spouse A/c No.
Bank’s Name Branch
IFS Code
Note 1: Please attach a copy of the first page of passbook/cancelled cheque/document showing the name of Account Holder. (The
name should be the same in the bank account, this form and the office records.)
Note 2: Please ensure that the Government servant is the Primary Account holder in the Joint Account
Note 3: In case Head of Office is satisfied that it is not possible for the retiring Government servant to open a joint account for
reasons beyond his/her control, this requirement may be relaxed.

4. Details of member of the family of Government servant who has been authorised under Rule 57(3) to submit this Form on behalf
of the retiring/retired Government servant:
Name Relationship with the
Government servant
Aadhaar No.*(voluntary) Nationality
Flat/House No./Bldg. Name Street/Locality
Village & Post Office/Block City & District
State Pin Code
Telephone No. (If any) Mobile No.
E-mail ID Reasons why Government
servant is not able to submit
this form

5. I desire to commute % of my pension under Central Civil Services (Pension) Rules, 2021 in accordance with the
provisions of the Central Civil Services (Commutation of Pension) Rules, 1981.

Note : A member of family who has been authorised under Rule 57(3) to submit this Form on behalf of the retiring/retired
Government servant shall not be eligible to apply for commutation of a percentage of pension.

6. Indicate whether family pension is also admissible from any other source- (Tick whichever is applicable)
Military
 State Govt.
Public sector undertaking/ autonomous body/ local fund under the Central or State Govt.

7. Whether any departmental or judicial proceedings pending against the Government servant? If so, the details thereof. ........

8. Whether any member of the family (other than spouse) is proposed to be co-authorised for family pension?
(If yes, please attach Form 8.) ......Yes/No

9. Whether the Government servant wants to receive Pension Payment Order (PPO) in Office through Head of Office? ..... Yes/No

Declarations:
*(1) I am satisfied with the length of qualifying service to be reckoned for pension and gratuity, as intimated by the Head of Office
under Rule 57(1)(c)
OR
I am not satisfied with the length of qualifying service to be reckoned for pension and gratuity, as intimated by the Head of Office
under Rule 57(1)(c) and I have submitted a representation in this respect separately.
OR

I have not been intimated about the length of qualifying service to be reckoned for pension and gratuity.

*Tick the statement which is applicable.

*(2) I am satisfied with the emoluments and average emoluments to be reckoned for pension and gratuity, as intimated by the
Head of Office under Rule 57(1)(c).
OR
I am not satisfied with the emoluments and average emoluments to be reckoned for pension and gratuity, as intimated by the Head
of Office under Rule 57(1)(c) and I have submitted a representation in this respect separately.
OR

I have not been intimated about the emoluments and average emoluments to be reckoned for pension and gratuity.

*Tick the statement which is applicable.

(3) I am aware that future good conduct of the pensioner/family pensioner shall be an implied condition for every grant of
pension/family pension and its continuance.

Enclosures: As per list attached

Place:

Date: ( Signature of Government servant/Family member (with name) authorised to

submit this Form)

Note 1: Commutation of pension is optional. Item 5 may be struck off if the retiring Government servant does not desire to
commute a percentage of pension.
Note 2: A separate application for commutation of superannuation pension in Form 1-A of Central Civil Services (Commutation
of Pension) Rules, 1981 is required to be submitted in case the retiring/retired Government servant desires to apply for commutation of
pension after submission of this form.
Note 3: Commutation of pension after one year or for commutation of pension in case of compulsory retirement
pension/invalid pension/compassionate allowance will be applied in Form-2 of Central Civil Services (Commutation of Pension) Rules,
1981.

*Providing Aadhaar No. is voluntary. However, if it is provided, consent to link it to bank account and also for authentication of identity
from UIDAI for pension related purpose only, is presumed.

List of Documents to be attached with Form 6

1. Two specimen signatures (to be furnished in a separate sheet). If the claimant cannot sign his/her name then he/she is
required to put the impression of his/her left/right thumb on the document in lieu of specimen signature.
2. Form 8, if a family member is proposed to be co-authorised for family pension. In accordance with Rule 63(1), the following
members of family are eligible for co-authorisation for family pension along with spouse, if there is no other member of family
eligible for family pension before them:

• Disabled child/ children (Disability certificate to be attached for co-authorisation.)

• Dependent parents.

• Disabled siblings. (Disability certificate to be attached for co-authorisation.)

3. Three copies of Joint photograph with spouse or, if it is not possible to submit joint photograph with spouse, separate
photographs of self and spouse, along with three copies of photograph of the member or members of the family whose
names are to be included in the Pension Payment Order as a co-authorised family pensioner. (Photographs to be attested by
Head of Office).
4. Form 4 – Details of Family.
5. Undertaking in Format 9 for refunding any excess payment made by the pension disbursing bank.
6. Nomination for Gratuity, Central Government Employees' Group Insurance Scheme and General Provident Fund in Common
Nomination Form –Form 3.
7. Nomination for arrears of pension and commuted value of pension (if applied for commutation of pension) in common
nomination form - Form A.
8. Undertaking in Format 1 ( applicable for those who served in Security-related or Intelligence Organizations referred to in rule
7 of the Central Civil Services (Pension) Rules, 2021).
9. Form for submitting details under Anubhav (optional).
10. Form of option for availing Medical facilities of Central Government Health Scheme or Fixed Medical Allowance after
retirement
11. Photocopy of the first page of Pass Book of the Bank Account in which the pension is to be credited or any other bank
document showing the name and account details of Account Holder
12. Copy of PAN Card
 FORM -1
See Rules 5(2), 6(1) 12,13,(1) & (2), & (2), 16(1) & (2)

FORM OF APPLICATION FOR COMPUTATION OF A

FRACTION OF PENSION WITHOUT MEDICAL EXAMINATION.
To be submitted in duplicate after retirement but within one year of the date of retirement.

PART- I
To,
The Financial Commissioner,
ESIC, Hqrs. Office,
CIG road, Panchdeep Bhawan
New Delhi-110002.

Sub:- Computation of Pension without medical examination.

Sir/Madam,

I desire to commute a fraction of my pension as indicated below in accordance with the

provisions of the Central civil Services (Commutation of Pension) Rules, 1981. The necessary
particulars are furnished below:-
1. Name ( in Block Letter)

2. Father’s Name (Also Husband’s name in the case of a

female Government Servant)
3. Designation at the time of retirement

4. Name of Office/Deptt./Ministry in which employed

5. Date of birth (in Christian era)

6. Date of retirement.

7. Class of pension of which retired

8. Amount of pension authorized (in case final amount of

pension has not been authorized, indicate the amount of
provisional pension sanctioned under Rule 64 of the Central
Civil Service (pension) Rules, 1972.
9. Fraction of pension proposed to be commuted

10 Designation of the Accounts Officer who authorized the

pension and the number and the date of the pension
Payment Order, is issued
11 Disbursing Authority for payment of pension

12 (a) Treasury/Sub-treasure) (Name and

complete address of the treasury/sub-treasury to
be indicated)
(b) (1) Branch of the Nationalized Bank with complete
Place :-
Date:- Signature:
Postal Address:-
Note:- The Payment of commuted value of pension shall be made through the disbursing authority
from which pension is being drawn. It is not open to an applicant to draw the commuted value of
pension from a disbursing authority other than the disbursing authority from which pension is being
drawn.
 The applicant should indicate the fraction of the amount of monthly pension (subject to a
maximum of one-third thereof) which he desired to commute and not the amount in rupees.
** Strike out which is not applicable.
 PART –II

ACKNOWLEDGEMENT

Received from Shri/Smt./Km. _______________________________ application in part- I of From – I for

the commutation of a fraction of pension without medical examination.

Date: Signature:_______________________

Place: _____________________ Head of Office:___________________

Note:- This acknowledgement is to be signed, stamped and date signature and is to be detached from the
Form and handed over to the applicant. If the for has been received by post. It is has to be acknowledged on
the same day and the acknowledgement sent under registered over.
__________________________________________________________________________________

PART _ III

ACKNOWLEDGEMENT

Forwarded to the Accounts Officer (here indicate address and designation

_________________________________________________________________
With the remarks:-
1. a) That the particulars furnished by the applicant in Part- I have been verified and are correct.

b) The applicant is eligible to get a fraction of his pension commuted without medical examination.

c) The commuted value of pension determined with reference to the table applicable at present come
to Rs. ______________/-

d) The amount of residuary pension after commutation will be Rs._________________/-

2. It is requested that further action to authorize the payment of the amount of commuted value of
pension may be taken as in Rule- 15 of Central Civil Services (Commutation of Pension) Rule, 1980.

3. The receipt to Part-I of the Form has been acknowledged in Part-II which has been forwarded
separately to the application on __________________.

4. The commuted value of pension is debitable to Head of Accounts.

Date:- Signature:-

Place:- Head of Office:-

DECLARATION UNDER SUB-PARA (III) (D) OF RULES 65 OF CHAPTER - IV

I hereby declare that I have neither applied for nor received any pension or gratuity in respect
of any position of the service included in this application and in respect of which pension, gratuity is
claimed herein, nor shall I submit an application hereafter without quoting a reference to this
application and the order which may be passed therein.

Place : ……………………………………………..

Date: ……………………………………………….

Identification mark / Height in respect of Sh. / Smt. / Km. ……………………………………………………………

1. Height …………………………………………………

2. Identification Mark. ……………………………….

Attested (Gazetted Officer)

(STAMP)
 ANNEXURE-I
ENCLOURES TO FORM – 5/14.

i) PASSPORT SIZE PHOTOGRAPH OF SMT / SHRI _____________________________________

PASSPORT SIZE
PHOTOGRAPH

ii) HEIGHT:- PENSIONER/

FAMILY PENSIONER
iii) PERSONAL IDENTIFICATIONS MARKS:-
a) ___________________________________________________________

b) _____________________________________________________________

iv) SPECIMEN SIGNATURE:-

a) __________________________ a)________________________________

b) __________________________ b)________________________________

c) __________________________ c)________________________________

ATTESTED:-

SIGNATURE:-

DEGNATION:-

OFFICE STAMP:-
 SPECIMEN SIGNATURE

Pensioner Family Pensioner

1. __________________________ 1. ________________________________

2. __________________________ 2. ________________________________

3. __________________________ 3. ________________________________

ATTESTED:-

SIGNATURE:-

DEGNATION:-

OFFICE STAMP:-
 FORM “A”
(See Rules – 5)
Pension Disbursing Authority/Head of Office
(Name of Bank/Treasury/Post Office/Accounts Office, etc.)
Place:___________________________________________________
I, ____________________________ (Name of the Pensioner in capital letters) hereby
nominate the person named below, under Rule-5 of the payment of arrears of pension
(nomination) Rules, 1993.
Name & Address of Relationship with the If Nominee is minor
the Nominee Pensioner Date of Birth Name and address Name & address
of person who may of other nominee
receive the said under (Col. 1)
pension, during the predeceases the
nominee minority. Pensioner.
1. 2. 3. 4. 5.

Relationship with the Date of Birth if the other Name and address of Contingency on happening
Pensioner Nominee is minor person who may receiv the of which nomination shall
commuted value of pension become invalid.
during the other nominee’s
minority
6. 7. 8. 9.

Place:
Date:- Signature :-
Postal Address:-

Signature of witness________________________________
Name & Address

Signature of pension Disbursing Authority/

Head of Office

Acknowledgement to be sent by the pension Disbursing Authority / Head Office.

Certified that application /nomination has been received from ________________________ (Name of
Pensioner) whose address is ___________________________________________.

Place:
Date:-
Signature of pension Disbursing Authority/
Bank/Treasury/Post office/Head of Office
Full Address:-
 FORM - 5
(See Rules – 7)
To,
Head of Office,
__________________________,
__________________________,
I, ____________________________ (Name of the Pensioner in capital letters) hereby
nominate the person named below, under Rule-7 of the Central Services (Commutation of
Pension) Rules, 1981.
Name & Address of Relationship with the If Nominee is minor
the Nominee Pensioner Date of Birth Name and address Name & address
of person who may of other nominee
receive the said under (Col. 1)
pension, during the predeceases the
nominee minority. Pensioner.
1. 2. 3. 4. 5.

Relationship with the Date of Birth if the other Name and address of Contingency on happening
Pensioner Nominee is minor person who may receive the of which nomination shall
commuted value of pension become invalid.
during the other nominee’s
minority
6. 7. 8. 9.

Place:
Date:- Signature :-
Postal Address:-

Signature of witness________________________________
Name & Address

Signature of Head Office

Stamp

Acknowledgement to be sent by the pension Disbursing Authority / Head Office.

Certified that application /nomination has been received from ________________________ (Name of
Pensioner) whose address is ___________________________________________.

Place:
Date:-
Signature of Head Office
Full Address:-
(G.I. Deptt. Of pension and Pensioner’s welfare, Notification No. 34(5) 83-Pension Unit, dated the
17th April, 1985, published as S.O. No. 1870 in the Gazette of India, dated the 4th May, 1985).
 UNDERTAKING
I _____________________________________________________________________
S/0, W/O ___________________________________________________________________
certified that ESIC accommodation is not provided to me till date.

Date:- Signature of
Government Servant
Palce:-
 UNDERTAKING
I _____________________________________________________________________
S/0, W/O ___________________________________________________________________
do hereby undertake that I will refund the amount paid me in account of Pension / Death-
cum-Retirement Gratuity / Commuted value Pension in Lump-sum, in case found excess in
due course.

Date:- Signature of
Government Servant
Palce:- Designation:
 UNDERTAKING

I hereby undertake that any ESIC accommodation is not allotted to me till date and
nothing is due against me regarding any accommodation.

Date:- Signature of
Government Servant
Palce:- Designation:
Name of the Office:-

No Due Certificate
It is certified that the following dues are outstanding against Sh.
………………………………………………………. Designation ……………………… of this
office, who is to retire/retired from service on …………………………….. ,
 On account of accommodation allotted by the corporation Rs. …………
 On account of others outstanding dues Rs. ………………..
i.e TA/DA, HBA, MCA, L.T.C,etc
If no amount is outstanding, may be shown as ‘NIL”

Signature
Designation