DETAILS OF FAMILY OF GOVERNMENT SERVANT

1.

Name of the Government Servant

2.

Designation

3.

Date of birth

4.

Date of appointment

5.

Details of the members of my family as on:-

_______________________
_______________________

-----------------------------------------------------------------------------------------------------------------------------S.No Name of the

Date of birth
Relationship
Initial of the
member of
with the Govt
head of the Office
family.
Servant
------------------------------------------------------------------------------------------------------------------------------

I hereby undertake to keep the above particulars upto date by notifying to the audit office/bead of
Office any addition or alteration.

Place:- Bandipur

Signature of Govt
Servant
ATTESTED

Form 6
NOMINATION FOR BENEFITS UNDER THE CENTRAL GOVT EMPLOYEES INSURANCE
SCHEME.
When the Govt servant has family and wishes to nominate one member or more than one member
thereof.
I, hereby nominate the person(s) mentioned below, he/she/they is/are member(s) of my family and
confer on him/them the right to receive the extent specified below any amount that may be sanctioned by
the Central Govt under the Central Govt Employed Group Insurance Scheme 1990 in the event of my
death while in service or which having become payable on my attaining the age of superannuation may
remain un paid at my death.
-----------------------------------------------------------------------------------------------------------------------------S.No Name and address of nominee/nominees Relationship with Govt servant
Age
------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------Share to be paid
Contingencies on the happening of
Name, address and relationship of
to each
which the nomination shall become
the person if any, to whom the
invalid.
nominee shall pass in the event
of his predeceasing the Govt Servant
------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------NB: The Govt Servant should draw line across the blank space below his last entry to prevent insertion
of any names he has signed.
Dated this____________day __________2003__________At______________________________
Signatures of two witness
1.-----------------------------------------------------------------------------------------2.------------------------------------------------------------------------------------------

Signature of Govt
servant
-----------------------------------------------------------------------------------------------------------------------------This column should be filled in so as to cover the whole amount that may be payable under the Insurance
Scheme.

FORMS OF NOMINATION FOR G P FUND

First Schedule ( Rule 5 (3) )
When the subscriber has no family and wishes to nominate one person.
I having no family as defined in Rule 2 of the General provident Fund (Central Services ) Rules
1960, hereby nominate the person mentioned below to receive the amount that may stand to my credit in
the Fund, in the event of my death before that amount has become payable, or having become payable has
not been paid.
Name and address of
Nominee

Relationship
with
subscriber

Age

Contingencies on the
happening of which
the nomination shall
become invalid

Name,
address
and
relation-ship
of
the
person/persons if any to
whom the right of the
nominee shall pass in the
event of the nominee
predeceasing the
subscriber

Dated this ________day of______________2003 at_________________________________

Two witnesses to signature
1.

No.______________________Rank________________
Name________________________________

2.

No.______________________Rank________________

Signature of
Subscriber
No.____________________

Name________________________________

Rank___________________
Name___________________

ATTESTED

FORM E
NOMINATION FOR FAMILY PENSION
I. No.___________________ Rank_____________ Name _________________
_____________hereby nominate the persons mentioned below, who are members of my family to receive
in the order shown below, the family pension which may be granted by govt in the event of my death after
completion of 10 yrs qualifying service.
------------------------------------------------------------------------------------------------------------------S/No.

Name & Address

Relationship
Date of
Whether
of Nominee
with subscriber
birth/age
married/unmarried
-------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------NB. The subscriber should draw lines across blank space below the last entry in prevent the incretion
of any name after he has signed.
This nomination supersedes the nomination made by earlier on_______________ which stands
cancelled
Dated, this_____________ Day of___________month___________year___________.
Witness:-(Name and Signature.)
1.No._________________Rank___________Name______________________Sig__________.
2.No._________________Rank___________Name______________________Sig__________.

Signature of Individual
------------------------------------------------------------------------------------------------------------------( To be filled in by the Head of Office in case of death)

NOMINATION FOR FINANCIAL ASSISTANCE OUT OF BSF BEN FUND

No. ____________________Rank_______________ Name_______________________

________________here by nominate the person/persons mentioned below who is/are member of my
family and to confer the right to receive the financial assistance from BSF Ben fund that may be
sanctioned by the Government in the event of my death.
Name and address
of nominee

Relationship

age

Contingencies on the happening of

which the nomination shall become
invalided.
-------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------The details of my family members are as under:Father__________________________

Mother_________________________
Children
1._____________________________

Date of birth_____________________________

2. _____________________________

_____________________________

3. _____________________________

_____________________________

4. _____________________________

_____________________________

COUNTER SIGNED

Signature of Govt servant

( in block letter )
IRLA. No_________________________
Rank

_________________________

Name

_________________________

NOMINATION FOR DEATH-CUM-RETIREMENT GRATUITY

When the Officer has a family and wished to nominate one member thereof.
I Hereby nominate the person mentioned below, who is a member of my family, and
confer on him the right to receive any gratuity that may be sanctioned by Government in the event of my
death while in service and the right to receive on my death any gratuity which, having become admissible
to me on retirement, may remain unpaid at my death.
Name and address
of nominee

Relationship
with Officer

Age

Contingencies on the
happening of which
the nomination
shall become invalid.

Name, address and relationship of the

person or persons if any, to whom the
right conferred on the nominee shall
pass in the event of the nominee
predeceasing the officer or the nominee
dying after the death of the Officer
but before receiving payment of the
gratuity.

This nomination supersedes the nomination made by me earlier on ________________________

Amount for share of

gratuity payable to
each

which stand cancelled

PROFORMA FOR ACKNOWLEDGING THE RECEIPT OF THE NOMINATION FORM BY

THE HEAD OF OFFICE/AUDIT OFFICER.
To.
-----------------------------------------------------------------------------------------In acknowledging the receipt of your nomination dated __________________cancellation dated
_______________________of the nomination

made earlier, in respect of D.C.R.G in Form

_____________________I am to state that they have been duly placed on record.

Date______________________

Signature of Head of Office

Designation ______________