NOMINATION DECLARARTION

I hereby declare that the Home town _______________________

Of mine is mentioned in service record is correct and it is situated at a distance of _____
Kms. Approximately from _____________Railway station.
ATTESTED BY

Signature of Govt. Servant

NO.____________________
Name__________________
Unit____________________

MARRIAGE DECLARATION
I hereby declare that I have one living wife/husband with me, named
Smt/Shri
Signature of Govt.servant
NO.____________________
Name__________________
Unit____________________
ATTESTED BY

SIGNATURE OF HOO

DECLARATION OF FAMILY MEMBERS

Name of the Govt. servant

Designation

Date of appointment

Date of birth

:
Details of family members as on

SL.NO. NAME OF FAMILY MEMBERS

RELATION WITH GOVT.

SERVANT

1.
2.
3.
4.
5.
6.
I do hereby undertake to keep the above particulars up to date by certifying to the
audit officer /HOO in addition or alternation dated day of .at.
Witness: 1)
2).
ATTESTED

Signature of Govt. servant

NO.____________________
Name__________________
Unit

SIGNATURE OF HOO

NOMINATION FOR FAMILY PENSION

I NO.
Rank
Name
hereby
nominate the person (s) mentioned below who is/are member of my family to receive in order
whom below the family pension which may be granted by Govt. in the event of my death after
completion of 10 years of qualifying service.
Name and address of nominee(s)

Relationship
with Govt.
servant.

Age

Whether
married or
unmarried

The officer should draw lines across blank space below the last entry to prevent
the insertion of any time after he has signed.
Dated______ _______

at ______hrs.

Witness:1)..
2).
ATTESTED
Signature of Govt. servant
No
Rank.
Name.

ATTESTED

SIGNATURE OF H.O.O.

NOMINATION FOR BENEFITS UNDER THE RISK FUND SCHEME OF CRPF

Name and address of Nominee((s)

Relation with
the Govt.
servant

Age

Share to be paid to
each
For nonrecurring
benefit

Contingencies on the happening Name, address and relationship to the person , if any to
on which the nomination shall whom the right of nominee shall pass in the event of his
become invalid.
predeceasing the Govt. servant

Note :- 1.
2.

In respect of an un-married Govt. Servant the words on acquiring

Family are also to be col-5 such a nomination will automatically become
invalid when family is acquired.
This nomination will be filled in very carefully and the individual should
himself/herself change the nomination on getting married.

Signature of two witness:-.

1).
2).

ATTESTED

Signature of Govt. servant

No

Rank.
Name.

SIGNATURE OF H.O.O.
FORM NO.-8
NOMINATION FOR BENEFITS UNDER THE CENTRAL GOVERNEMENT
EMPLOYEESGROUP INSURANCE SCHEME, 1990
When the Govt. servant has a family and wishes to nominate one member or more than
on member thereof.
I, No. .
Rank Name
hereby nominate the person(s) mentioned below, who
is/are members of my family, and confer on him/then the right to receive to the extent
specified below any amount that may be sanctioned by the Central Government under the
Central Government Employees 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 unpaid at my death.
Name and addresses of nominee(s)
in the event of subscribers death
(1)

Relationship
with
subscriber
(2)

Age
(3)

Amount or Share of
accumulations to be
paid to each
(4)

Name address and relationship of the person, if

any, to whom the right of the nominee shall pass in
his predeceasing the subscriber (6)
Contingencies on the happening of
which the nomination shall become
invalid (5)

Date ____________ this day of ____________ 200__________ at _____________

Two witness to signature:1.
2.
ATTESTED

Signature of Govt. Servant

SIGNATURE OF H.O.O.
FORM 2
See Rule 53 (1)
Nomination for Retirement Gratuity/Death Gratuity
When the Govt. servant has a family and wishes to nominate one member or more
than on person
I,
No..
Rank
.
Name
., having no family, hereby nominate the
person/persons mentioned below and confer on him/them the right to receive, to the
extent specified below, any gratuity the payment of which may be authorized by the
Central Government in the event of my death while in service and the right to receive on
my death, to the extent specified below, any gratuity, which having become admissible to
me on retirement may remain unpaid at my death :Name and addresses of
Relationship
Age
Amount or Share of
nominee/nominees
with the Govt.
(3)
gratuity payable to
(1)
Servant
each
(2)
(4)

Name,address,relationship and age of the person or persons, if

any to whom the right conferred on the nominee predeceasing the
Govt. servant or the nominee dying after the death of the Govt.
servant but before receiving payment of gratuity (5)

Amount or share of
gratuity payable to
each (6)

This nomination supersedes the nomination made by me earlier which stands cancelled.
Date ____________ this day of ____________ 200__________ at _____________
Two witness to signature:1.
2.
Signature of Govt. Servant
ATTESTED

SIGNATURE OF H.O.O.
FORM NO. 9C
GPF SUBSCRIBER NOMINATION
When the subscriber has family and wished to nominates more than one person
I,
No.
..
Rank
..
Name
.. Having no family as defined in rule 2 of the Central provident
Fund (Central Service) 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 persons in the manner shown
below against their names :Name and addresses of nominee(s)
in the event of subscribers death
(1)

Relationship
with
subscriber
(2)

Age
(3)

Amount or Share of
accumulations to be
paid to each
(4)

Name address and relationship of the person, if

any, to whom the right of the nominee shall pass in
his predeceasing the subscriber (6)

Contingencies*on the happening of

which the nomination shall become
invalid (5)

Date ____________ this day of ____________ 200__________ at _____________

* Where a subscriber who has no family makes a nomination; he shall specify in this
column that the nomination shall become invalid in the event of his subsequently on
acquiring a family. Two witness to signature.
1.
2.
Signature of Govt. Servant
ATTESTED

SIGNATURE OF HOO
FIRST SCHEDULE RULE 53 (8) GPF ACCOUNT NO.
I,

No.

Rank

Name..

hereby

nominate the person(s) mentioned below who is/are members/non-members of my family

as defined in rule 2 of the General Provident Fund (Central) below in the eve of my death
before there amount is become payable or having has not been paid.
1.

Name and full address of the nominee :-

2.

Relationship with subscriber :-

3.

Share of payable to such nominees :-

5.

Contingencies on the happening nomination :-

6.

Name & address relationship if any to whom

right to nominee shall pass in the event of
his/her pre-recessing the subscriber.

Signature of witness persons :1.

..

2.

ATTESTED

Signature of Govt. servant

No

Rank.
Name.
SIGNATURE OF H.O.O.