COURT CASE

REGISTERED
Telephone:022-25075455 Fax.022-25075621
Email: [email protected] Naval Pension Office
180022056_0
Tollfree : c/o INS Tanaji
Sion Trombay Road
Mankhurd
-
Mumbai 400 088

PEN/600/SP/ Court Case Of Nov 18

The ZSBIZSWO

PROCESSING AND FORWARDING OF PENSION FORMS DOCUMENTS OF

SPECIAL PENSION CLAIMANTS (EX,SAILORS/FAMILI ES)
DIlKI

1. Refer to following: -

(a) Hon'ble Supreme Court dated 27 Oct 16.

(b) Hon'ble Supreme Court dated 27 Sep 18.
(c) GOI/DESW letter 4(10)12017-D(Pen/Legal) dated 22 Oct 18.

2. ln order to expedite the process of making relevant Pension Form set available
to the Special Pension claimants (as defined in the order listed at Para 1), this office is
hosting relevant Form-set on its website (http://indiannavy.nic.in/navpen). This Form-set
!, is to be duly downloaded by the claimants and appropriate print-out, as described
below, is to be taken for processing their respective cases through the concerned
ZSBs. The type of print-outs (of Pension Form-set) which is to be taken by the
claimants are as described below: -

(a) For the pages numbered from 1 to 12 - Back to back.

(b) For the pages numbered fr:om 13 to 22 - Single side of each page.
aa

3. The necessary lnstruction for filling-up the Pension Forms is also the part of l
Forms being uploaded which needs to be iownloaded and kept back with claimants for
reference.

4. ZSBs are therefore requested to consider this signed (and scanned) letter copy
(available on NAVPEN website) as the authentic letter for an ex-sailor to approach ZSB ,

office for enabling processing of their pension claims and for ZSBs to fonvard the
completed documents to the Record Office (NAVPEN). ,:
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5, . lt. may: be noted that the Hon'ble Supreme Court has clearly directed' all
.
stakeholders for quick implementation of their brder (refer Para 1) and:any undue or
unjustifiable delay may invite adverse stricturesl summons from'the Hoilble Co-urt.i
Hence.,.there exist p necessirry to process the Special fension,cases,of the ex-sailors

(RK Nagar) l ,
Captain
Sr. Staff Officer (Pension)
for Logistics Officer-i n-Charge
i
 COURT CASE
REGISTERED
Telephone: 022-2507 5455 F ax: 022-2507 5621
Email: navpen-navy@nic. in Naval Pension Office
Tollfree : 1800220560 cio INS Tanaji
Sion Trombay Road
Mankhurd
Mumbai400 088

PEN/600ISP/ Court Case 03 Nov 18

Shri

FORWARDTN9 OF PENSTON FORMS FOR GRANT OF SPECIAL PENSION

NAME RANK P.NO.
DATE OF ENROLMENT: DATE OF DISCHARQE:

1. Refer to GOI MoD letter 4(10)12017/D(Pen/Legal) dated 22 Ocl18.

2. A set of pension forms are attached herewith. You are requested to take back to
back side printout of the pages numbered from 01 lo 12 and on sinqle side of eagh
page for the pages numbered '13 to 22 (on 44 size paper). These Forms-set are required
to be then filled-up completely, and wherever required necessary signatures of Zila
Sainik Welfare Officer be endorsed.

3. Further, fonruard the completed Forms to this office along with all the necessary
documents (readable, legible and recognisable copies only).

4. On receipt of your Pension Forms, your claim will be submitted to the PCDA (P),
Allahabad/ PCDA (N), Mumbai for issue of Special Pension PPO" lt may be noted that
your Special Pension claim cannot be processed in the absence of said
documents.

U
($r{ *' ;TrrRl RK Nagar)
*ued /Captain
Efi!"6 TUFF'$fu'rfiG?FT)
Sr. Staff Officer (Pension)
Tt {is{rfr6r q}Trtl3lffi
for Logistics Officer-in-Charge
 1

INSTRUCTION FOR FILLING UP THE SPECIAL PENSION FORM

1. On receipt of a set of pension forms, you have to ensure that following documents are
forwarded to the Naval Pension Office through respective Zila Sainik Board as per the time frame
mentioned against each for timely sanction of pension.

2. While filling up the forms you are requested to note the following points for easy
completion:-

(a) Pension Forms and photographs are required to be attested by the Zila Sainik
Board.

(b) In column 11 of the IN 245 you are required to write only last rank held by you and
effecting date

(c) In column 09 & 24 of the IN 245 you are advised to write the permanent home
address i.e. Spouse name, House Name/No., Post Office, Village, District, State and Pin
code.

(d) Column 18 of the IN 245 you are required to write the Bank Particulars for drawing
your pension after discharge, Pension account is to be opened only in any of the Branch
of the Bank which is authorized by the Reserve Bank of India for Defence Pension
transaction in your particular district. The names of authorised banks for drawal of
pension are as under: -

(i) State Bank of India (ii) Punjab National Bank

(iii) Allahabad Bank (iv) Andhra Bank
(v) Bank of India (vi) Bank of Maharashtra
(vii) Canara Bank (viii) Central Bank of India
(ix) Corporation Bank (x) Indian Bank
(xi) Indian Overseas Bank (xii) Syndicate Bank
(xiii) UCO Bank (xiv) Union Bank of India
(xv) United Bank of India (xvi) Bank of Baroda
(xvii) Dena Bank (xviii) Oriental Bank of Commerce
(xix) New Bank of India (xx) Punjab Sind Bank
(xxi) Vijay Bank (xxii) Axis Bank
(xxiii) ICICI Bank (xxiv) HDFC
(xxv) IDBI
(e) In case your district has been separated from any old district, you are requested
write the old district name in bracket, so that necessary action can be taken for granting
the pension, in the correct bank.

(f) Your name should be correct as per the service record, as well as it should be
matched with Aadhaar Card, PAN Card, Voter ID Card etc. Photocopy of Aadhaar Card
for self and dependents duly attested by Zila Sainik Board must be enclosed with pension
forms.

3. Annexure A (Details of Family).

(a) You are required to write the full date of birth of the individuals (for example 01
Jan 94 of 01.01.94). You are requested to write the correct name as per your marriage
declaration and Service Documents. In case of any difference in the name of self and
dependents, you are required to enclose the documents as per IHQ MoD(N) / DESA
letter DX/VSF/165/15 dated 18 Feb 15 (photocopy attached) along with the pension
forms.
Contd…2/-
 2

(b) In case you are having any handicapped/mentally retarded child/children, you are
requested to indicate the same against their name in details of family (Annex A) and
following documents may also forwarded to this office as supporting documents:-
(i) Four copies of medical certificate issued by the Specialist medical officer
of the rank of Civil / Surgeon / Cmde / Brigadier and photograph of the child to be
pasted on each certificate and the same is to be attested by the Zila Sainik Board.
(ii) Photocopies of original birth certificate duly attested by the Zila Sainik
Board.
4. Requirement of Photographs:-

(a) Married Sailors: Joint photo of self and wife: Four Copies
(b) Unmarried sailors/divorce/widower: Self Photographs: Four Copies
(c) Disposal of the Photographs:
(i) One photograph is to be pasted on the details of family (Annexure A) and
to be attested by the Zila Sainik Board.
(ii) One Photographs is to be pasted on the page 6 of descriptive roll and to
be attested by the Zila Sainik Board.
(iii) Two photographs are to be attached with the pension claim in an envelope
duly attested on reverse side by the Zila Sainik Board. Name, Rank and Number
is to be written on the reverse side of the photograph.
5. If you have not declared your marriage to NAVPEN then you are requested to forward the
following documents to this office along with the Pension Forms: -
(a) Original Court Affidavit signed by the First Class executive magistrate
(b) Marriage Certificate duly attested by Zila Sainik Welfare Officer.
6. If you are a divorcee / widower, you are requested to forward the following documents to
this Bureau along with the pension forms:-
(a) In case of widower death certificate duly attested by the Zila Sainik Board.
(b) In case of Divorcee –Court Decree regarding Divorce
7. In case of discrepancies, NAVPEN (Naval Pension Office) will not be processing your
pension claims to NPO / CDA (N) for issue of Pension Payment Order without proper verification.
Therefore you are advised to check to pension forms thoroughly before forwarding the same to
NAVPEN, so that the unwarranted delay can be avoided.

NOTE: Please detach these Instructions from the Pension Form set and keep as
guidelines.
 3
SPECIAL PENSION (10 YEARS OF SERVICE) In Lieu of I.N 245

ROLL OF A SAILOR APPOINTED PRIOR TO 03 JUL 1976 AND DISCHARGED ON OR AFTER 03 JUL 1976
Auth: The Hon’ble Supreme Court Order dated 27 Sep 18 and GOI, MoD {Dpt. Of Ex-Servicemen Welfare
D(Pension/Legal)} Letter No. 4(10)/2017(D(Pen/Legal) dated 22 Oct 2018
(TO BE PREPARED IN DUPLICATE) Aadhar No. _____________
E-mail ID _______________
Mobile No. _____________

1) Number :________________ ___________________________

2) Name & Rank (in Block Letter) :________________ ___________________________
3) Last Ship/Establishment before discharge : ___________________________________________
4) Date of Birth :________________ ___________________________
5) Date of Enrolment :________________ ___________________________
6) Age on Enrolment :________________ ___________________________
7) Date of Discharge :________________ ___________________________
8) Gallantry Award, if any (attach copy of Authority) :________________ _______________________
9) Address (with Pin Code) :________________ ____________________________
_____________________________________________
____________________
10) Identification mark :________________ ____________________________
11) Details of Promotion of last rank held : Vide ‘BOP’Number ____________________________
w.e.f ________________________________________
12) Rate of pay last admitted Rs. __________________________________________
13) (a) Date of discharge Vide Release Serial Number ______________________
(b) Total service on date of discharge: _____________ _____________________________
14) Period not counted as qualifying service for Pension: __________________________________
15) Any Previous IN, IAF or Army service which may count towards pension. Gratuity as verified by the CDA
(Navy) ( Proof to be enclosed)

16) Character ( Very Good / Good / Satisfactory) : _____________________________________

17) Prominent occurrence during life or service (all records of held service from the date of commencement to
the date of termination should be written here)

18) Place and Channel of Payment

(a) Treasury : _____________________________________
(b) DPDO : _____________________________________
(c) Bank Details :
(i) Name of Bank : ______________________________________
(ii) A/C No. (Single / Joint) : ______________________________________
(iii) Place of Bank : ______________________________________
(iv) District : ______________________________________
(v) State (with PIN Code) : ______________________________________
19) Pension for which recommended : Special Pension @ Rs. ____________________
(Rupees) ____________________________________________________w.e.f_________________

20) Other allowances, if any, to which entitled

when pensioned : ______________________________________
 4
21) Cause of discharge vide article 2520 (ii) : TRANSFERRED TO PENSION ESTABLISHMENT /
Regs. (for Indian Navy) LOCAL DISCHARGE FROM UNIT

22) Whether he was granted any Pension : _______________________________________

previously, If so, the PPO number and
Commencement date of pension. Circular
notifying pension should be quoted

23) Was he recommended any time for reduction of

Pension, If yes, give reasons : _______________________________________

24) Details of eligible dependents (who are to be paid Family Pension on demise of current pensioner) in
following format:-

Sr. Name Relationship Address with PIN Code Aadhar No.

with Pensioner

Note:- Eligible dependants for seeking family pension would mandatorily follow the sequence namely, wife,
handicapped child, eldest child (if eligible).

Three signatures of (Name, Rank & Number of Ex-serviceman) ___________________________________ are as

appended below:-

(a) ______________________
(b) ______________________
(c) ______________________
I
ATTESTED
Station __________________
Date ____________________
Zila Sainik Board
II
I certify that the particulars given in the ‘Roll’ are correct as far as can be ascertained from the record of
the NAVPEN and admissibility of Special Pension is recommended for sanction under the extant Rules {(see Rules 5,
8, 69 and 80 of of the Navy (Pension) Regs 1964}.

For Logistics Officer-in-charge

III
Recommended and Special Pension Sanctioned

Naval Pension Office

C/O INS Tanaji
Sion-Trombay Road
Mankhurd, Mumbai – 400 088
Date :__________________ For Logistics-Officer-in-Charge
 5
SPECIAL PENSION (10 YEARS OF SERVICE) In Lieu of I.N 245

ROLL OF A SAILOR APPOINTED PRIOR TO 03 JUL 1976 AND DISCHARGED ON OR AFTER 03 JUL 1976
Auth: The Hon’ble Supreme Court Order dated 27 Sep 18 and GOI, MoD {Dpt. Of Ex-Servicemen Welfare
D(Pension/Legal)} Letter No. 4(10)/2017(D(Pen/Legal) dated 22 Oct 2018
(TO BE PREPARED IN DUPLICATE) Aadhar No. _____________
E-mail ID _______________
Mobile No. _____________

1) Number :________________ ___________________________

2) Name & Rank (in Block Letter) :________________ ___________________________
3) Last Ship/Establishment before discharge : ___________________________________________
4) Date of Birth :________________ ___________________________
5) Date of Enrolment :________________ ___________________________
6) Age on Enrolment :________________ ___________________________
7) Date of Discharge :________________ ___________________________
8) Gallantry Award, if any (attach copy of Authority) :________________ _______________________
9) Address (with Pin Code) :________________ ____________________________
_____________________________________________
____________________
10) Identification mark :________________ ____________________________
11) Details of Promotion of last rank held : Vide ‘BOP’Number ____________________________
w.e.f ________________________________________
12) Rate of pay last admitted Rs. __________________________________________
13) (a) Date of discharge Vide Release Serial Number ______________________
(b) Total service on date of discharge: _____________ _____________________________
14) Period not counted as qualifying service for Pension: __________________________________
15) Any Previous IN, IAF or Army service which may count towards pension. Gratuity as verified by the CDA
(Navy) ( Proof to be enclosed)

16) Character ( Very Good / Good / Satisfactory) : _____________________________________

17) Prominent occurrence during life or service (all records of held service from the date of commencement to
the date of termination should be written here)

18) Place and Channel of Payment

(a) Treasury : _____________________________________
(b) DPDO : _____________________________________
(c) Bank Details :
(i) Name of Bank : ______________________________________
(ii) A/C No. (Single / Joint) : ______________________________________
(iii) Place of Bank : ______________________________________
(iv) District : ______________________________________
(v) State (with PIN Code) : ______________________________________
19) Pension for which recommended : Special Pension @ Rs. ____________________
(Rupees) ____________________________________________________w.e.f_________________

20) Other allowances, if any, to which entitled

when pensioned : ______________________________________
21) Cause of discharge vide article 2520 (ii) : TRANSFERRED TO PENSION ESTABLISHMENT /
Regs. (for Indian Navy) LOCAL DISCHARGE FROM UNIT

22) Whether he was granted any Pension : _______________________________________

previously, If so, the PPO number and
Commencement date of pension. Circular
notifying pension should be quoted

23) Was he recommended any time for reduction of

Pension, If yes, give reasons : _______________________________________

24) Details of eligible dependents (who are to be paid Family Pension on demise of current pensioner) in
following format:-

Sr. Name Relationship Address with PIN Code Aadhar No.

with Pensioner

Note:- Eligible dependants for seeking family pension would mandatorily follow the sequence namely, wife,
handicapped child, eldest child (if eligible).

Three signatures of (Name, Rank & Number of Ex-serviceman) ___________________________________ are as

appended below:-

(a) ______________________
(b) ______________________
(c) ______________________
I
ATTESTED
Station __________________
Date ____________________
Zila Sainik Board
II
I certify that the particulars given in the ‘Roll’ are correct as far as can be ascertained from the record of
the NAVPEN and admissibility of Special Pension is recommended for sanction under the extant Rules {(see Rules 5,
8, 69 and 80 of of the Navy (Pension) Regs 1964}.

For Logistics Officer-in-charge

III
Recommended and Special Pension Sanctioned

Naval Pension Office

C/O INS Tanaji
Sion-Trombay Road
Mankhurd, Mumbai – 400 088
Date :__________________ For Logistics-Officer-in-Charge
 7

PENSION DISBURSING OFFICE

Treasury: ______________________ Bank: _____________________________

Address: ______________________ Address: ___________________________
Serial: _____________ No.________ Account No. ________________________
Head Office ____________________ Head Office _________________________
___________________________________________________________________

DESCRIPTIVE ROLL OF

Name : _____________________ Rank ________________ Corps : INDIAN NAVY

Number __________________
----------------------------------------------------------------------------------------------------------------

INSTRUCTIONS

THUMB AND FINGER IMPRESSIONS AND SPECIMEN SIGNATURES

1. A Small quantity of printer‟s ink should be well rubbed on a tin slab until a very
thin even layer is formed. The balls of the thumb and of all the fingers of the left hand of
the individual after being wiped should be laid on the inked slab and rolled from side (not
rubbed) until sufficiently inked and then lightly and carefully the thumb be rolled on paper
on which the print is to taken, in such a way that the thumb lines are clearly impressed
on it. It must be specially borne in mind that any side movement, either during applying
or removing the thumb will cause a smudge or spoil the impression and therefore to be
avoided.

2. The impression on page 2 is required for permanent record in the audit office.
Page 5 is detached and retained by the Pension Disbursing Officer. In the case of
Family Pensioner, the impression on the duplicate copy of I.A.F.A- 366 or A-368 will be
removed from there and pasted in the space provided on pages 2 and 5 of this from.

3. However, in the case of pensioner in respect of whom joint photographs in the

civil dress with his wife have been furnished and who are literate enough to sign their
names in English, Hindi or any official regional language, instead of taking their thumb
and finger impression as means of identification, they will be required to affix three
specimen Signatures on page 2 and 6 of the Descriptive Roll.
 8
DESCRIPTIVE ROLL

Class No ________________ Serial No ________________

Paying Station _______________ Channel of Payment _____________
Name, Rank

Height when
Service No

previous to
Date From

Age When
pensioned

pensioned

pensioned

pensioned
and Corps

Length of

Colour of
hair and
Father‟s

service
Name
-----

-----

-----

-----
which

being

Eyes
Complexion
Corps and

Year and
Months

Months

Figure
Years

Cms.
Rank

Days

Days

Face
For What Country of Disability
----- Class or Tribe

period Residence of and other

Paragna or Tehsil

pension
granted family
----- Religon
City or Village

granted
----- District

----- State

(Life Time or for temporarily

Lesser Period) for a Fixed
-----

-----

Period

Date on which
pension is to be
ceased

Prominent Service and character Identification Mark Remarks on examination by

whilst serving officer paying pension

Three specimen signatures of Individual

1.________________ 2._________________ 3.________________ Aadhar No. ___________
Three specimen signatures of his Wife
1.________________ 2._________________ 3.________________ Aadhar No. ___________
The period of service in each corps (i.e. Army/Navy/Air Force) and rank in which such Service
was performed must be separately entered.

Station : _______________ ATTESTED

Date : ______________ Zila Sainik Board

 9

In the event of an extension, the period of extension with number and date of the pension extension
order / circular and pension payment order should be noted in red ink. The same procedure should be
followed in the case of pension being made permanent.

In the column “Prominent Service” the number of battles, allegedly in which the pensioner may have
served and the occasions on which medals or other rewards were received are to be entered.

In the column identification Marks the size and situation of any wounds, scar, mole or other peculiarities
tending to Identification of the pensioner are to be entered by medical officers of units / regiments in
their own handwriting in plane intelligible terms after a careful examination of each individual.

Name and relationship of next of kin or other Signature and Name, Rank and
person to whom arrears of pension are to be paid Number of Pensioner
at the demise of pensioner

Signature of two guarantors who are already the recipient of pension and to whom the individual is known

Signature of the Guarantors Name of pension Disbursing Office (in case Address
the Guarantors are Military Pensioners and
the Treasury / Head Office)

Name Serial No.

Taken before
(Full Signature and Designation of
Pension Paying Officer)

Description of Pension Amount Ps. Amount in words Authority Pension

etc. Rs. Payment Order
1. Pension per month
2. Relief As applicable
3. Personal
Allowance subedar
or Risaldar Major
Per Month
4. DCRG, Personal
Allowance A D C
Per Month

5. Gallantry Award /
Capitalize Value

ATTESTED

Staff Officer (Pension)

For Logistics Officer-in-charge, NAVPEN
 10

Certified that _____________________________________________________________

the above named has been paid in my presence and advance of Rupees _______________
_________________________________________ on this ________________________
day of ____________________________________

Comdg.

Station _________________
Dated __________________

Register, Page No. Pension Paying Officer

Recorded in

________________________________________________________________________

In the column “Next of Kin” the names, ages and occupation of two of the pensioner‟s sons or
nearest male relations are invariably to be noted, also the name of the person to whom he
wishes to award all arrears, due to him, at the time of his death to be paid. Indian Military
pensioners are permitted to nominate alternative heirs in order of priority for the purpose of
payment of any arrears of pension due to the death of the deceased pensioners. Heirs so
nominated will be serially numbered in order of priority of right to the payment of the pensioner
at the time of the first payment after 1st January in each year.

State the controller‟s pension circular/pension payment order in which the continuance of
personal allowance on transfer to the pension list was notified.

State the Controller‟s pension circular/pension payment order in which the continuance of
annuity on transfer to the pension list was notified

Expunge where no advance is given.

 11

PARTICULARS OF TRANSFERS
NOT TO BE COMPLETED BY UNIT

Pensioner Authority Last payment made

Transferred for transfer

From To Monthly Rate To Amount Signature

Rate of of what paid of pension
pension payment date paying
officer

Rs. Ps. Rs. Ps.

 12

Impression should be taken in as small a compass as possible consistent with clearness

(See instruction on Page. 1)

(A) Three specimen signatures of individual

1) ______________________________
2) ______________________________
3) ______________________________

(B) Three specimen signatures of his wife

1) ______________________________
2) ______________________________
3) ______________________________
ATTESTED

Staff Officer (Pension)

For Logistics Officer-in-Charge, NAVPEN
Latest Passport size photographs of the individual with his wife in civil dress duly attested

Family for this purpose means family as

defined in A.I 2/S/6 and corresponding
instructions in Navy and Air Force side

Note : (a) Photo of self and wife in case of married sailors.

(b) Self photo in case of unmarried /
Divorced / Widower Sailor. Photo is to be
i) In case of Divorce, Legal affixed duly
Documents to be enclosed attested by the
ii) In case of widower, Death Certificate of Zila Sainik Board
the wife to be enclosed. as per note

Note : Photo affixed here is required to be countersigned

by the Zila Sainik Board
 13

TO BE RETURNED TO ;

ACKNOWLEGMENT THE LOGISTICS Officer-in-charge

for Staff Officer (Pension)
Naval Pension Office
C/O INS Tanaji
Sion-Trombay Road
Mankhurd, Mumbai – 400 088.

(a) Pensioner‟s Service No. ____________________________________________

(b) Pensioner‟s Rank ____________________________________________

(c) Pensioner‟s Name ____________________________________________

(d) T/S No./H/O./Account No. ____________________________________________

(e) P.P.O No. ____________________________________________

I acknowledge the receipt of IAF A 369 In respect of the above Pensioner.

Station : _____________________ _____________________

Date: _______________________ Signature
Pension Paying Officer

Note: All the above to be filled in before the Descriptive Roll is sent to the Pension Disbursing Officer and
Despatched to The Logistics Officer-in-charge, Naval Pension Office on the above address
 14

CERTIFICATE FOR BANK

(By Pensioner)

I, Shri/Smt___________________________________________________________

_____________________________hereby certify that my Pension/Family Pension Account

details are as follows and that I will not change the Pension Account at least till receipt of the first
pension:-

A/c No. : ______________________________________________

Name of Bank : ______________________________________________

BSR Code of : ______________________________________________

Paying Branch

Address of Bank : ______________________________________________

_______________________________________________

Post Office _______________________________________________

District _______________________________________________

State ______________________________Pin:______________

Date : Signature : _______________________

Name : _______________________

Rank : _____________No._______

II

CERTIFICATE BY BANK

Certify that ________________________________________________________________

_________________________________________________________________________

_______________________________________(Name and Address of Bank) is authorized

for disbursement of Defence Pension. Further, the address of the CPPC/Link Branch with

BSR Code is ______________________________________________________________

_________________________________________________ (Address, including Pin Code)

(Seal) Manager

Date____________ _________________Bank
 15

ANNEXURE 'A'
DETAILS OF FAMILY
Name _____________________________Service No. __________Rank ___________
Date of Retirement / Discharge / Invalidment _________________________
Details of the Members of my family as on ___________________________
Name of the Member of Date of Birth Relationship with the Whether the Children Physically
S.No
Family (dd-mm-yy) individual Handicapped or Mentally retarded

1.
2.
3.
4.
5.
6.
7.
8.

I hereby undertake to keep the above given particulars upto date by notifying the addition
/ alterations, if any, to the Record Office.

Date: ____________ ____________________

Signature of Sailor

Place: ___________ COUNTERSIGNED

Date : ____________ Zila Sainik Board

Family for this purpose means family as defined in A.I 2/S/6 and corresponding
Instruction in Navy {Rule 120 of the Navy (Pension) Regs 1964} and Air Force side.

Note:
(a) Photo of self and wife (in case of married sailors).
(b) Self photo ( in case of unmarried / Divorced / Widower Sailors).
(i) In case of Divorce, Legal Documents to be enclosed.
(ii) In case of Widower, Death Certificate of wife to be enclosed.
Verified and found correct with reference to entries recorded in Kindered Roll
Portion of Sheet Roll.

Photo is to be
affixed duly
attested by the
Zila Sainik
Staff Officer (Pension)
Board as per
note for Logistics officer-in-charge
Naval Pension Office

Note: Photo affixed here is required to be countersigned

by the Zila Sainik Board
 DECLARATION FOR ANTICIPATORY PENSION
Whereas the Controller of Defence Accounts (Pensions), Navy Mumbai has consented
provisionally to advance to me towards Pension Rupees ____________________________
____________________________P.M. Relief Rupees _____________________________
__________________________________________and Death-cum-Retirement Gratuity Rupees
____________________________________________________________ only in anticipation
of the completion of the enquiries and documents necessary to determine my pension
entitlement, namely, pension, Relief and Death-cum-Retirement Gratuity. I hereby acknowledge
that I fully understand that the same are subject to revision on the completion of the necessary
enquiries and documents, and I promise to raise no objection to such revision on the ground that
the provisional payment made to me exceed that award to which I may be eventually found
entitled. I further promise to repay any amount advanced to me in excess of that which I may be
eventually found entitled.

Signature __________________

Name _____________________

Rank:__________ No. ________

Date: ____________________

HVY / ASK / MSN / 21/6/89

FORM OF DECLARATION
( To be completed by the applicant in receipt of anticipatory pension)

Whereas the Controller of Defence Accounts (Pension), Navy Mumbai has consented
provisionally to advance to me the sum of Rs. being the commuted value of a portion of the
anticipatory pension in anticipation of the completion of the enquiries necessary to enable him to
fix the amount of my pension and consequently the part of pension that may be
commuted. I fully understand that the commuted value now paid to me is subject to revision on
completion of the necessary formal enquiries and I promise the have no objection to such
revision of the ground that the provisional amount now to be paid to me as the commuted value
of the part anticipatory pension exceeds the amount of which I may be eventually found entitled
found entitled. I further promise to repay either in cash or by deducting from subsequent
payments of pension any amount advanced to me in excess of the amount to which I may be
eventually found entitled.

________________________
Station : __________________ Sailor's Signature

Dated : ___________________
 DECLARATION TO BE SIGNED BY SERVICE PENSIONERS

I understand that the service pension which is being sanctioned in my favour is subject to
my future good conduct. I also understand that the pension is liable to be forfeited if I am
convicted by a court of law or a crime of political and non political nature. The term
'GRAVE MIS CONDUCT' also includes " Attempts to forment communal trouble or
indulgence in activities which promote class harted"

Signature _____________________

Rank_________________________

Per.No._______________________

Date_________________________

DECLARATION FOR RECOVERY OF GOVERNMENT DUES

I (Name Rank & No) ________________________________________________

________________________________________________agree to the recovery of

Government dues hereafter, being effected from pension, if detected later.

Signature__________________

ATTESTED

Dated ________________ Zilla Sainik Board

 18

SPECIMEN LETTER OF UNDERTAKING BY THE PENSIONER

Date _________

To

The Branch Manager

____________________________ (Bank)

_____________________________ (Branch and address)

Dear Sir,

Payment of pension under A/C No. through your Bank

In consideration of your having, at my request, agreed to make payment of

pension due to me every month by credit to my account with you. I the undersigned
agree and undertake to refund or make good any amount to which I am not entitled or
any amount which may be credited to my account in excess of the amount to which I am
or would be entitled. I further hereby undertake and agree to bind myself and my heirs,
successor, executors and administrators to indemnify the bank from the against any loss,
suffered or incurred by the bank in so crediting my pension to my account under the
scheme and to forthwith pay the same to the bank and also irrevocable authorise the
bank to recover the amount due by debit to my said account or any other account /
deposits belonging to me in the possession of the bank.

Yours faithfully,

Signature

Name

Address

Witnesses:

(1) Signature …………………… (2) Signature ……………………

Name …………………… Name ……………………

Address …………………… Address ……………………

Date …………………… Date ……………………

 19
FORM OF CERTIFICATE OF NON- EMPLOYMENT/ RE-EMPLOYMENT
FROM THE DATE OF DISCHARGE ( ), TILL DATE
(In triplicate)

1. I declare that I have not been serving in any capacity either in a Govt. Deptt./
Office, Company, Corporation, Autonomous body or Society or Central or State
Government or Union Territory or Local Fund during the half-year ended May/November.

OR

I declare that I have been employed/ re-employed in the office of

which is a part of / financed by Government and was in receipt
of the following monthly rates of emoluments during the half year ended May/
November or during the month of falling,
with in the said half year.

(a) Pay

Special Pay

Allowances

(Including DA,ADA, etc)

OR

(b) Honorarium

Further that the orders of my re-employment do/ do not stipulate my

pension being held in abeyance during the re-employment.

*2. I declare that I have not accepted any commercial employment in India.

OR

I declare that I have accepted commercial employment in India, after obtaining

previous sanction of the Central Govt. and none of the conditions, if any, attached
thereto by Govt. has been violated.

OR

I declare that I have accepted commercial employment in India without obtaining

the previous sanction of the Central Government.

Note- This declaration is required to be given for a period of two years from the date of
retirement.
Cont….2/-
 -20-

**3. I declare that I have not accepted any commercial employment under a Govt.
outside India/ an International organization of which the Govt. of India is not a member.

OR

I declare that I have accepted a Commercial employment under a Govt. outside

India/ an International Organization of which the Govt. of India is not a member after
obtaining the previous sanction of the Central Govt. have been deviated form .

OR

I declare that I have accepted a commercial employment under a Govt. outside

India/ an International organization of which the Govt. of India is not a member without
obtaining the previous sanction of the Central Govt.

Signature

Name of pensioner

Place PPO No

Date TS/ PS No.

COUNTERSIGNED

Gazetted Officer

(*) Certificate at (2) is to furnished by retired Defence Civilian Group „A‟ Officers/
Commissioned Officers of and above the rank of Colonel / Captain / Group Captain in
the Army, Navy and Air Force respectively.

(**) Certificate at (3) is to be furnished by retired Defence Civilian group „A‟ officers
and Commissioned Officers of all ranks.
 (To be filled in Duplicate)
FINAL KINDERED ROLL FORM
(No further amendments will be accepted)

Name ___________________________ Rank ___________________ No. _______________ Mobile No__________________

Aadhar No._________________________ (Attach photo copy) Email. ID _____________________________

Note: (a) Particulars of all living/dependent relatives should be filled up in the Form. Copy of Documentary proof for name, date of birth and marriage.
e.g. Birth Certificate / PAN Card /Aadhar Card / Passport / Voter ID/passport to be attached. Otherwise the Form will be considered null and void.
(b) This Kindred Roll will be considered as the Final Kindred Roll before retirement and details mentioned in this will be used for verification of Pension /
ECHS and for use in all other Release Formalities.
(c) This Form is to be prepared in duplicate, ink signed by endorsing the date by the sailor and countersigned by the Divisional Officer/HODs/
Commanding Officer. The SDs (Page no. 2 Family particulars) is to be filled up in ink and countersigned by Divisional Officer. The form is to be sent
along with the Pension forms and audited SDs to NAVPEN / Pension Section along with all documents mentioned at Para (a).

Relationship Name Date of Aadhar Card No Residence Address Name of heir / estate name Percentage
Birth (Attach photo copy) Village, Post Office, (of persons) to whom (%)
Tehsil, District & Pin code) estate should be made over
on behalf of heir.

Wife

Father 1.

Mother

Son/ 1
Daughter
2.
2

Brother /Sister 1

Date & Form

of Marriage

Countersigned
Sailor's Signature ______________
Name ____________________________
Rank and Number __________________ Zila Sainik Board

Dated : ____________
 (To be filled in Duplicate)
FINAL KINDERED ROLL FORM
(No further amendments will be accepted)

Name ___________________________ Rank ___________________ No. _______________ Mobile No__________________

Aadhar No._________________________ (Attach photo copy) Email. ID _____________________________

Note: (a) Particulars of all living/dependent relatives should be filled up in the Form. Copy of Documentary proof for name, date of birth and marriage.
e.g. Birth Certificate / PAN Card /Aadhar Card / Passport / Voter ID/passport to be attached. Otherwise the Form will be considered null and void.
(b) This Kindred Roll will be considered as the Final Kindred Roll before retirement and details mentioned in this will be used for verification of Pension /
ECHS and for use in all other Release Formalities.
(c) This Form is to be prepared in duplicate, ink signed by endorsing the date by the sailor and countersigned by the Divisional Officer/HODs/
Commanding Officer. The SDs (Page no. 2 Family particulars) is to be filled up in ink and countersigned by Divisional Officer. The form is to be sent
along with the Pension forms and audited SDs to NAVPEN / Pension Section along with all documents mentioned at Para (a).

Relationship Name Date of Aadhar Card No Residence Address Name of heir / estate name Percentage
Birth (Attach photo copy) Village, Post Office, (of persons) to whom (%)
Tehsil, District & Pin code) estate should be made over
on behalf of heir.

Wife

Father 1.

Mother

Son/ 1
Daughter
2.
2

Brother /Sister 1

Date & Form

of Marriage

Countersigned
Sailor's Signature ______________
Name ____________________________
Rank and Number __________________ Zila Sainik Board

Dated : ____________