n -* . 3 + ? F ~ 00 Union Bank of India

Department of Personnel & HR Terminal Benefit Division, Central Office, Mumbai.

239, Vidhan Bhavan Marg, Union Bank Bhavan, Mumbai - 400 021

Staff Circular No: 5943 16th January 201 3

All Branches / Offices

Highlights of the circular - Extension of another pension option to Officers voluntarily retired under OSR 19(1) on or after 29.09.1995

- Stipulated period of submission of option -21 .01.2013 to 21.03.201 3

Second option for Pension - Extending the benefit to officers who took Voluntary

Retirement under Requlation 19(1) of OSR 1979 on or after 29.09.1995

1. Attention i s invited to Staff circular no:5690 dated 27.08.2010 extending another

option to join the pension scheme to certain classes of employees and their family

members who did not opt for pension earlier, in terms of the Memorandum of

Settlement for Workmen and Joint Note for officers both dated 27.04.2010.

2. As per para no.7 of the said circular, Officers voluntarily retired under Regulation

19(1) of Officers' Service Regulations 1979 were not eligible for exercising pension

option as also other employees I officers like who resigned, dismissed, terminated and

compulsorily retired.

3. Now IBA has advised the Banks to extend the benefit of exercising another option to

join the Pension Scheme to those officerslfamily of deceased officers who have taken

Voluntary Retirement under Regulation 19(1) of OSR 1979 on or after 29.09.1995

vide their Letter no. CIRIHR 8 lR/2012-13lG216213 dated 09.1 1.2012.

4. Bank's Board had accorded approval for the same in i t s meeting dated 27.12.201 2.

5. The extension of the benefit of exercising another option to join the existing Pension

Scheme is strictly in accordance with the terms & conditions laid down in the Joint

Note dated 27.04.201 0.

6. The salient features of the Pension Scheme now extended to officers/family of

deceased officers Voluntarily Retired under Regulation 19(1) of OSR 1979 are as under:

i. The Scheme i s applicable to officers who have taken Voluntary Retirement under

Regulation 19(1) of Officers' Service Regulations 1979 on or after 29.09.1995 and

were not Pension optees.

ii. Option for pension as above, can also be exercised by family of deceased officers

who had taken Voluntary Retirement under Regulation 19(1) of Officers' Service

Regulations 1979 on or after 29.09.1995 and were not Pension optees.

iii. The Voluntary Retirees or family of such deceased officer, opting for pension as

above, have to contribute towards the Pension fund as under:

Category

with interest paid at the time of voluntary retirement &

of the above amount. contribution to Provident

Contribution to be made towards Pension Fund

I - - (Retiree's share in the funding gap)

(1 ) Bank's contribution to Provident

I November 2007.

Voluntarily retired on or after 27.04.201 0

iv. Pension / Family Pension shall be payable with effect from 27.1 1.2009 or from the

date of Voluntary Retirement whichever is later, (as per para (8) of the Joint Note

dated 27.04.2010) under Regulation 29 of Bank Employees' Pension Regulations.

~u'nd with interest paid at the time of I voluntary retirement & (2) 2.8 times of revised pay for

7. The stipulated period for exercising pension option and for depositing contribution

towards pension fund to be eligible for Pension Scheme wi l l be as under :

I Submission o f ensi ion o ~ t i o n fo rm 1 60 davs 1 21.01.2013 t o 21.03.2013 1 1 Depositing ;ontribut/on towards 30 da is 1 22.03.201 3 to 20.04.201 3 1 1 ensi ion fund I I I I - I

It may be noted that the eligible applicants must adhere t o the above schedule.

Belated requests 1 applications shall not be entertained.

8. The procedure for submission of option / pension forms wi l l be as under :

Sr. No. - (a)

Category

Officers voluntarily reti red under OSR 19(1) on or after 29.09.1995 but prior to 27.04.201 0 and had not opted for pension earlier.

Forms 1 documents to be furnished

(1) Option form (Annexure I) (2) Form No. 3 (Application for Pension (3) Form No.5A(if commutation of pension desired) (4) Form No.7(Part I, II tir Ill) (Medical Reports i f commutation of pension desired) (5) Form No. 8 (Nomination) (6) Verified copy of

Voluntary Retirement (under OSR 19(1)) Acceptance Memorandurn (7) Letter containing 1. Details of emoluments and PF received and 2. Request for netting the amount of commutation of pension and arrears of pension against the amount refundable towards Pension Fund to be eligible for pension (if so desired) (Annexure Ill-A). (8)Letter of Undertaking for recovery of excess payments in respect of pension.

Mode of submission

Set of forms and documents to be submitted to the nearest branchloffi ce

Stipulated period of

submission 60 days (from 21 .01.2013 to 21.03.2013)

Further Course of

branch /office will acknowledge receipt of ' the same and promptly forward the

to the ' Ekional Office 1 Controlling Office under which jurisdiction the branch 1 office where retiree last worked falls.

Sr. No. - (b)

Category

Eligible family of deceased Officers who had voluntarily retired under OSR 19(1) on or after 29.09.1995 but prior to 27.04.201 0 and had not opted for pension earlier.

Forms I documents to be furnished

(1) Option form (Annexure I) (2) Form No.4 (Application for family pension) (3) Verified copy of Voluntary Retirement (Under OSR 19(1)) Acceptance Memorandum (4) Form No.13 (Certificate of Re- marriage / Marriage) (5) Letter containing request for netting the amount of arrears of family pension against the amount refundable towards Pension Fund to be eligible for pension (i f so desired) (Annexure Ill-B). (6) Letter of Undertaking for recovery of excess payments in respect of pension.

Mode of submission

Set of forms and documents to be submitted to the nearest branchloffi ce

Stipulated period of

submission

60 days (from 21.01.2013 to 21.03.2013)

Further Course of

action

Nearest branch I office wil l acknowledge receipt of the same and promptly forward the set to the Regional Office I Controlling Office under which jurisdiction the branch 1 office where retiree last worked falls.

Sr. No.

I (c)

Category

Officers voluntarily retired under OSR 19(1) on or after 27.04.201 0 and had not opted for pension earlier.

Forms / documents to I be furnished

(Annexure II) ( 2 ) Form No.3

I (Application Pension) (3) Form No.SA(if commutation of pension desired) (4) Form No.7(Part I, II 6 Ill) (Medical Reports i f commutation of pension desired) (5) Form No. 8 (Nomination) ( 6 ) Verified copy of Voluntary Retirement (under OSR 19(1)) Acceptance Memorandum (7) Letter containing 1. Details of emoluments and PF received 2. Request for netting the amount of commutation of pension and arrears of pension against the amount refundable towards Pension Fund to be eligible for pension (if so desired) (Annexure Ill-A). (8) Letter of Undertaking for recovery of excess payments in respect of pension

Mode of submission

I Set of forms and documents to be submitted to the nearest branchloffi ce

Stipulated period of

submission 60 days (from 21.01.2013 to 21.03.2013)

Further Course of

action Nearest branch /office , wi l l acknowledge receipt of the same and promptly forward the set to the Regional Office / Controlling Office under which jurisdiction the branch / office where retiree last worked falls.

I Sr. No. -

(d)

Category

deceased officers who had voluntarily reti red under OSR 19(1) on or after 27.04.2010 and had not opted for pension earlier.

Forms I documents to be furnished

Eligible family of

(2) Form No.4 (Application for family pension) (3) Verified copy of Voluntary Retirement (Under OSR 19(1)) Acceptance Memorandum (4) Form No.13 (Certificate of Re- marriage / Marriage) (5) Letter containing request for netting the amount of arrears of family pension against the amount refundable towards Pension Fund to be eligible for pension (i f so desired) (Annexure Ill-B). ( 6 ) Letter of Undertakins for recovery of excess payments in respect of pension.

(1) Option form (Annexure II)

Mode of submission

Set of forms and documents to be submitted to the nearest branchloffi ce

Stipulated period of

submission 60 days (from 21 .01.2013 to 21.03.201 3)

Further Course of

action Nearest branch I office will acknowledge receipt of the same and promptly forward the set to the Regional Office I Controlling Office under which jurisdiction the branch 1 office where retiree last worked falls.

All the application forms mentioned above have been appended for ready reference.

Please note that officer / family of such officer not belonging to the above category

should not submit the above applications / documents.

9. The concerned Regional Office / Controlling Office under which the errlployee Last

worked shall follow the following procedure.

i. On receipt of relevant set of documents, the Regional Office shall scrutinize

the applications for eligibility as per Para 6, 7 and 8.

ii. If found eligible for pension, Regional Office shall prepare Worksheet for

Sanction of Pension (Annexure IV).

iii. Expenses incurred towards medical examination / tests are to be borne by the

retiree.

iv. Regional Office need not wait till the last date for sending the applications in

one lot, but are advised to send even single application as and when they are

received and their scrutiny i s over. This would enable to speed up the process

at the Central Office.

v. Regional Office shall send complete set along with worksheet to

The Asst. General Manager (HRM), Union Bank of India,

Department o f Personnel, Central Office, 8th Floor,

Union Bank Bhavan, 239 Vidhan Bhawan Marg,

Nariman Point, Mumbai - 400 021

10. On receiving all the necessary applications / documents, Pension Section, Central

Office will check the applicant's eligibility once again. The Department wil l compute

pension and the pension contribution to be deposited in the Pension Fund Account to

be eligible for pension as stated above and inform the applicant accordingly. Hence it

is necessary that the applicants provide correct postal address, telephone numbers

and e-mail id in the application form without fail. The applicant i s required to remit

the amount, as instructed by the Terminal Benefit Division, in the following account,

withln the stipulated period.

Account Number 1 37890 201 01 02148

I Title of the Account I Union Bank of India (Employees') Pension Fund ~

Branch, where the amount is remitted, amount must mention correct Provident Fund

Branch

Stipulated Period for depositing the amount

Account No. / Employee No. and Name of the applicant in the "Particulars" Column

while keying in the details in Finacle.

Nariman Point (Mumbai Main Office)

30 days (from 22.03.201 3 to 20.04.201 3)

11. All the Branch Heads / Departmental Heads are requested to bring this to the notice of

all the officers 1 family members of the deceased officers retired voluntarily under

OSR 19 (1) on or after 29.09.1995 from their branch 1 office and had not opted for

pension earlier. For this purpose branches are required to

i. Display the copy of the circular on the Bank's Notice Board for wide publicity.

ii. Provide a copy of this circular to the unions / associations locally, so that they

may convey the details of the scheme to their past and present members and

other voluntarily retired officers.

12.The circular wi l l be hosted in our Bank's website under

"About Us 3 Policies & Disclosures 3 Information for Retired Staff".

13. In order to avoid any last minute confusion, all the eligible officers / family members

are advised to submit the set of forms well in advance and not to wait till last date.

14. Far further clarification / assistance in this regard, you may contact Shri Prakash

Dhadve, Sr. Manager Pension Cell, Central Office on

Phone No.022-22023518 / 22896255

IP - 11 6250,

E-mail ID - pensioncell.staff@unionbankofinelia.com

(Hindi version follows)

R-

GENE LMA AGER(P&HR) YY

( Annexure I to Staff Circular I I No.5943 dated 16.01.2013

401 8% on Union Bank 3 f k @ k z ~ of India

Option form to be filled in by the Officers I Family of deceased Officers voluntarily retired on or after 29th September 1995

but prior to 27th April 2010 under Regulation 19(1) of Officers' Service Regulations 1979.

To The General Manager (P&HR), Department of Personnel, Union Bank of lndia Central office, Mumbai

i . I ................................................... .(Name), Employee No.. ....................... , had taken voluntary retirement under Union Bank of lndia (Officers') Service Regulation 19(1) on. ........................

ii. My spouse Shri I Smt. ......................................... Employee No ..................... had taken voluntary retirement under Union Bank of lndia (Officers') Service Regulation 19(1) on .......................... He I She expired on ..............................

(Strike out whichever is not applicable)

iii. I hereby declare that I have read and understood the terms of Joint Note dated 27.04.2010 for extending another option to join Pension Scheme. I have understood that the terms of the Joint Note have been arrived at on the basis of the Associations offering to contribute 30% of the initial funding gap assessed for extending another option for joining the pension scheme. I am agreeable to the said contribution of 30% towards the funding gap and hereby voluntarily opt for Bank's Pension Scheme as per the provisions of the said Joint Note. I undertake to refund the Bank's contribution to Provident Fund together with accrued interest thereon paid to me on my voluntary retirement plus an amount equal to 56% of the Bank's contribution to Provident Fund with interest received at the time of voluntary retirement being 30% contribution towards the initial funding gap in terms of Clause 3(c) of Joint Note dated 27.04.2010.

Date : ................................. ........................................... (Signature)

Name in Full : ......................................................................................... Contd ...

Annexure I t o Staff Circular No.5943 dated 16.01.201 3

Last Designation of the employee : .......................................................................

Present Residential Address : ...............................................................................

..................................................................................................................

Telephone / Mobile No. : ...............................................................................

e-mail ID : .......................................................................................................

Signature of the applicant attested.

........................................ Signature

of the official attesting the signature

Official's Name : ............................................... (Branch / Departmental Head)

P.A. No. .............................

Seal of the Branch / Department

Note : Additions / alterations in the text of the above form wil l render the option invalid. ...............................................................................................................

ACKNOWLEDGEMENT

Option Form as above received and forwarded to Pension Fund Section - Central Office (through Regional Office in case of branches) for completion of further procedure.

.......................... Signature

(Branch / Departmental Head)

............................................. Name of the Official :

Seal of the Branch / Department

No. 5943 dated 16.01.201 3

Yol* @ Union Bank 3ifbjf ikl~ of India

Option form to be filled in by the Officers I Family of deceased Officers voluntarily retired on or after 27th April 2010 under

Regulation 19(1) of Officers' Service Regulations 1979.

To The General Manager (P&HR), Department of Personnel, Union Bank of lndia Central office, Mumbai

i. I ......... ....................................( Name), Employee No .................. .............,, had taken voluntary retirement under Union Bank of lndia (Officers') Service Regulation 19(1) on. ........................

ii. My spouse Shri I Smt. ........................................ , Employee No.. ................... had taken voluntary retirement under Union Bank of lndia Officers' Service Regulation 19(1) on .......................... HeIShe expired on .................................

(Strike out whichever is not applicable)

iii. I hereby declare that I have read and understood the terms of Joint Note dated 27.04.2010 for extending another option to join Pension Scheme. I have understood that the terms of the Joint Note have been arrived at on the basis of the Associations offering to contribute 30% of the initial funding gap assessed for extending another option for join,@ the pension scheme. I am agreeable to the said contribution of 30% towards the initial funding gap and hereby voluntarily opt for Bank's Pension Scheme as per the provisions of the said Joint Note. I undertake to refund the Bank's contribution to Provident Fund together with accrued interest thereon paid to me on my voluntary retirement plus an amount equal to 2.8 times of my revised pay for the month of November 2007 representing my share in the 30% contribution mentioned above in terms of Clause (1) of Joint Note dated 27.04.2010.

Date : ................................. ........................................... (Signature)

Name in Full : ................................................................................. Contd.. .

Annexure II t o Staff Circular No. 5943 dated 16.01.201 3

Last Designation of the employee : ........................................................... ......

Present Residential Address : ......................................................................

Telephone / Mobile No. : ...........................................................................

e-mail ID : ...........................................................................................

Signature of the applicant attested.

........................................ Signature

of the official attesting the signature

............................................. Official's Name : (Branch / Departmental Head)

P.A. No. .............................

Seal of the Branch / Department

Note : Additions / alterations in the text of the above form will render the option invalid. ............................................................................................................

ACKNOWLEDGEMENT

Option Form as above received and forwarded to Pension Fund Section - Central Office (through Regional Office i n case of branches) for completion of further procedure.

.......................... Signature

(Branch / Departmental Head)

Name of the Official : .............................................

Seal of the Branch / Department

No. 5943 dated 16.01.201 3

Letter containing (1) Details of emoluments & Provident Fund received and (2) Request for netting the amount of commutation of pension and arrears of pension against the amount

refundable towards Pension Fund to be eligible for pension (i f so desired) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The General Manager (PEtHR), Department of Personnel, Union Bank of India Central office, Mumbai

Dear Sir,

Please refer to my application for pension option (Annexure I / II) dated

........... ..........., application for pension (Form No.3) dated ...................... and

application for commutation of pension (Form No.5A) dated ...................................

1) I give hereunder the details of (a) Emoluments necessary for colnputation of pension

and (b) Provident Fund received for computation of amount refundable by me.

(a) Emoluments drawn by me duritig 10 months prior to cessation of service :

Contd.. ..

Month & Year

TOTAL

Allowances h-lcrement

Basic Pay Of qualifying for Qualifying for ~ i ~ ~ d personal P.F. 8 D.A. -

Rs . Rs. Rs. Rs.

Annexure Ill-A t o Staff Circular No. 5943 dated 16.01.201 3

(b) Details of total amount of Bank's Contribution to PF (inclusive of interest) received by me :

Date

2) 1 hereby request for netting the amount of commutation of pension and arrears of

pension against the amount refundable by me towards Pension Fund to be eligible for

pension. (Please strike out if not desired.)

Amount (Rs.)

TOTAL

Date : ................................. ............................................. (Signature)

--

Name in Full : ...................................................................................

Employee No. 1 P. F. Account No. : .................................................................

No. 5943 dated 16.01.201 3

Request Letter for netting the amount of arrears of family pension against the amount refundable towards Pension Fund to be eligible for pension (if so desired)

The General Manager (PFtHR), Department of Personnel, Union Bank of India, Central office, Mumbai

Dear Sir,

Please refer to my application for pension option (Annexure I I II) dated

.................... .and application for family pension (Form No.4) dated ......................

I hereby request for netting the amount of arrears of family pension against the

amount refundable by me towards Pension Fund to be eligible for pension.

Date : ................................. ...................................... (Signature of the applicant)

Name of the applicant in Full : ................................................................

Employee's Name & P.F. Account No. : ...........................................................

No.5943 dated 16.01.201 3

Y a * 00 Union Bank ~~ of India

WORKSHEET FOR SANCTION OF PENSION

From :

Regional Office,

........................................................

........................................................

PART A (Common for both - retiree I family member)

To :

The General Manager (PEtHR),

Department of Personnel,

Central Office

1. Name of the Employee

2. P.F. No.

3. Date of Birth

4. Date of Joining

5. Date of cessation of service

REF. NO. DATE :

6. Reason of cessation of service : Voluntary Retirement under OSR 19 (1) (Copy of memorandum whereby Voluntary Retirement under OSR 19 (1) has been

7. Designation at the t.ime of Cessation of service

8. Branch I Department last worked

9. Qualifying Service as per Pension : ................ Years Regulations

10. Whether departmental or judicial : Yes 1 No proceedings instituted 1 pending? If yes, give details

Contd.. .

Annexure IV to Staff Circular No.5943 dated 16.01.201 3

11. Emoluments drawn during 10 months prior to cessation of service as per our records:

Month Et Year

TOTAL

12. Details of total amount of Bank's Contribution to PF (inclusive of interest) paid as per our records:

13. Amount of 2.8 times of revised pay for the month of November 2007 to be recovered / adjusted (only in case of voluntary retirement on or after 27.04.201 0)

Sr. Manager (P) 1 Chief Manager (P)

Seal of the RO

%i $m on UniDn Bank 3iivi@ar of India

FOR PENSIONOPTEE ONLY . .

. . FORM . . N0.3 . . . . .

APPLICATION FOR GRANT OF PENSION ON RETIREMENT

To The General Manager (P) Department of Personnel Union Bank of lndia 239, Vidhan Bhavan Marg Nariman Point Mumbai 400 021.

. - . . .

. Passport size .

PHOTOGRAPH .

alongwith spouse duly . attested by Branch

Managcr/Departmental' . Head

. . . . '

I retired / will retire from the Bank's service with effect .from and have .

opted for Union Bank of lndia Employees' Pension Scheme. Please sanction th= pension as

per the rules of the Bank. D desire to draw my pension from Branch

and request you to credit . the . monthly pension to my 58 A/c No. with

. ' Branch, Region. . .

. .

The necessary.details are as under :.

1. Name in full . .

' 2. PF No. . . . 3. Date of Birth

. . 4. Date of Joining . .

. .

5. Designation at the time of joining

6. Branch/Department last worked . 7. Name of the Region

8. Designation at the time of cessation .

Of service

9. Date of cessation of service and reason : Retirement/Vol. Retirement, etc.

10. Addition to qualifyfng service fn terms : . Of Pension -Regulations (applicable for the employees joined as specialists)

' 1 1. Name of the spouse . . . .

12. Date of birth of spouse

. .':.. 1 3. Data of fami!y members . . %,. %..

. . . .

S.No. Name . . ~elationshi~ Date of Birth i .

I hereby declare'that information furnished above is true to the best of my knowledge and I shall give any other information as and when required by the Bank.

Signature Address

Place: Date :

ii

iii

iv. , .

v,

ENSURE TO ENCLOSE AN ADDITIONAL PASSPORT SIZE PHOTOGRAPH JOINTLY WITH SPOUSE,

. .

. .

. .

ad* ~0 Union Bank 3?hti$l3al - of lndla

FORM -4

(Application for grant of Family Pension On the death of the Emplovee/Pensioner).

The General Manager (P), Department of Personnet-. Union Bank of India . .

Centrat Office Mum bai 480 021.

Sir,

I . regret very much .to inform you of the said demise . of . my husbandlwife ~ h r i l ~ m t . on . The relative death certificate is enclosed. . .

1. Details of the applicant

A. Full Name.

1) Widowlwidower . ii) Son/Daughter ?

A

iii) Guardian if the dqceased person is survived by minor child or children

0. S. 0. Alc. No.(lndividual) (15 DigitAccountno.),

C. Name of the Branch . .

D. Name of the Reion

2. . Name Et age of the surviving widow/widower and children of the deceased . . ,

employee1 pensioner.

Sr. No.

Occupation, if any

Name .

Relationship with the . . deceased person

. .

Date of birth by ~hristian era

3. Details of the deceased emplovee/pen~ioner

i) . ~u lk Name

ii ) PF Number . .

iii) Designation . iv) Branch/Dept. last worked 8 Zone :

V) Date of death vi) Pension payment order number :

4. -- Enclosures . 1. Passport size photographs of the applicant diily attested. 2. Certificate(s) of age (attested copies) showing the. date of birth of the

children. The certificate should be from the Municipal Authorities or from the head of the recognized school, if .the child i s studying in such school.

. 5. . indicate whether farnil; pension is admissible: from. any .other source Military or Stare Government and '/or a public sector

undertaking/ autonomous Wy/local fund under the Central or State Government. t ..?

Signature attested

Signature or left hand thumb . Impression of the applicant in

cast of illiterate Br. ~ a n a ~ e r l ~ e ~ a r t m e n t a l Head

Date:

Full residential Address: Witness:

1. Name:

Address

Signature

2. Name:

Address

Signature

n 4d * ~0 Union Bank

3&iftar of India

FORM NO. 5A (PART I)

APPLICATION IN DUPLICATE FOR COMMUTATION OF

PENSION SUBJECT TO MEDICAL EXAMINATION

To, ,

The General Manager(P) Department of Personnel, Union Bankof India, - 239, Vidhan Bahavan Marg, Mumbai 400 021.

C

Space far affixing attested

. passport size photograph

. . L

Dear Sir, . .

I desire to cornmute a fraction of my pension in accordance k i t h ~ n i o " f3kk of India Employees' Pension Resul,ations, 1995. ~n attested. copy of my photagraph is affixed on the .. .

' application and an unattested copy is' enclosed. The necessary particulars are furnished . . below:

1. Name in full-(in block letters) . .

3. Designation at the time of retirement : . . . . .

4. Braneh/Office last worked

5. Name of the Region

6. Date.of birth (as per Bank's service. record)

7.. Date of Joining the Bank

8. Date of retirement

9. Class of Pension

10. Fraction of pension proposed to be : commuted not exceeding 1 /3id thereof

11. S. 0. Account

12. Branch where pension i s payable

13. Name of the Region

Place:

Date : . .

Address :

(Signature)

- ' ACKNOWLEDGEMENT

Received from Shn'lSmt. IKum . .

Application for commutation df Pension subject to Medical Examination.

Place:

Date :

. .

Branch Manager/Departmental Head

Branch1 Dept.

44 * ~0 Union Bank 3mj~m of India

FORM NO. 7 (PART- I)

DECLARATION'BY THE PENSIONER FOR

FACILITATING MEDICAL EXAM1 NATION

BY THE BANK'S MEDICAL OFFICER

Space for affixing 'attested .

passport size photograph

. .

The applicant must complete this statement prior to his examination by the Bank's Medical Officer and must sign the declaration appended thereto in the presence of Bank's Medical Officer.

1. Name-in full (in block letters)

2; Date of birth (as per Bank's service recdrd ' : . '

3. Particulars regarding parents

a), Father's age, i f living B state of health :

b) Father's age at death and cause of death :

c) Mother's age, i f living 8 state of health :

d) Mother's age at death and cause of death : 2,.

. . -3.: i s .

. .4. Have you been considered for grant .of invalid .'rl .=: ~". -. . ... , . Pension? ..:I \ a*. ,<. - . . ii. L.:. If so, state the ground thereof, 92 c-: , ->.. %?:.. s*/ -

5.' Have you been granted leave on medical z.-. s.7 z ~ : . certificate during the last three years of r.; ; .

your service?

'If so, state periods of leave and nature of

illness

6. Have you during the last three years period . :

(a) suffered from any major illness requiring

hospitalization?

If so, the nature of illness 8 period of

hospitalization may please be indicated; or :

(b) undergone any major surgical operation: - -

(c ) lost or gained weight niarkedly .

DECLARATION BY THE APPI-ICANT

(To besigned'in the presence of the Bank's ~ed ica l Officer)

I declare all the above answers to be, to the most of my belief, true and correct.

I am fully aware that by willfully making a false statement or concealing d relevant fact, I shall incur the risk of losing the commutation.

Place:

Date:

Signature of Bank's ~edical Officer . .

Applicant's signature or thumb impression in case of illiterate applicant

n Crd * ~0 Union Bank

-3- of lndla

FORM NO. 7 (PART' Ill

Medical details of the Pensioner

(To be filled by the examining Medical Officer)

I . Apparent Age . . .

4. Describe any scars or identifyin; marks of the applicant: . .

5. Pulse rate

(a) Sitting . .

'(b) Standing

What is the character of pulse?

6. Blood Pressure (a) Systo!ic

(c) Diastolic 7. Is there any evidence of disease of the main organs? :

(a) Heart (b) Lungs (c) Liver (d) Spteen (e) Kidney

8. Investigations (wherever considered necessary by

the Bank's Medics[ Officer)

( i) Urine (State specific gravity) (ii) Blood (iii) X-ray Chest .

. .

(iv) E.G.G.

9. Any additional finding .

00 Union Bank of India

FORM NO, 7 (PART 111) - (Certificate of fitness for payment of Commutation of Pension)

(TQ be filled by the exam.ining Medical Officer)

IIWe have carefully examined ~ h r i / ~ ~ t . / ~ " r n . and . .

am/are of opinion that

HeIShe is in good bodily health and has the prospect of anmerage duration of life.

OR . .

-. He/She is not in good bodily health and . is . not a fit subject for

OR

Although he/she i s suffering form

helshe is considered f i t subject for commutation but hislher age for the purpose of commutation, i.e. the age next birthday should be taken to be (in words) years more than hidher actual age.

Place :

Date : . '

Signature .and designation of

examining Medical Officer

ad * 00 Union Bank 3 i i b i f . 3 ~ of India

. . . .

- FORM N0.8

NOMINATION FORM FOR COMMUTED VALLIE OF PENSION/ARREARS OF PENSION -

From:

Shri / Smt/ Kum. . .

Retired as

P.F. No.

Address

The General Manaser(P) ' - ' . '

~epartment of Personnel, ' Union Bank of India,

239, Vidhan Bahavan Marg, Mumbai 400 021.

Dear Sir,

I , hereby nominate the person/persons mentioned below, who idare members of my family to receive, to the extent specified against their names, the amomt of commuted value of Pension/arrears of Pension in the event of my death, which has become payable and remained unpaid.

Share/Proportion i n which commuted value of pension/arrears payable . to each nominee

Age Relationship with Pensioner

.

. .

Sr.No.. .

Fuli Name and Address of . the Nominee

.

(In case of nominee being minor, please give date of birth, name and address of the guardian who may receive his share.) .

'Fy

20 Dated at . this day of

- . ~ignature/~humb l'mpression Of the pensionei

Witnessed by :

1. Signature :

Full Name :

Address

2. Signature : Full Name : Address

. \ . f '

. . . . . - , , . -

UNION BANK OP I N D I A .

I . -

Form No. 1 3

I hereby declare that I have. not got re-married and I undertake to report such an event promptly to the Pension Disbursing Authority/Union Bank of India.

(Applicable 6nlv for widow/widower reai~ient of family pension and to be furnished onlv once)

or 1

I hersby dec la rk that I an, not rnarried/X have not got married durinq the past s i x months.

(To be submlzted by widowers and unmarried dauqhters once every six months in May

and November)

Signature :

Namc of the Pensioner :

Place :

Date :

P . P - 0 , No,

I certify to the best of my knowledge and belief that the above declaration is correct.

Signature of a: responsible Officer or a wel'l known person

Place :

D a t e :

N a m e :

D e s i g n a t i o n :

LETrER OF UNDERTAKING FOR RECOVERY OF EXCESS PAYMENTS MADE ON ACCOUNT OF PENSION SE-TTLEMENT

The General Manager (PEtHR), Department of Personnel, Union Bank of lndia Central office, M~~mbai

Dear Sir,

I have applied for pension and commutation of pension 1 family pension vide

application dated .......................... in terms of Staff Circular

No ........... dated ...................... under Union Bank of India (Employees') Pension

Regulations 1995 and subsequent amendments thereto. I am eligible for pensionary benefits

as applied by me.

I hereby irrevocably authorise you to make any recoveries 1 adjustments out of my

future pension, i f it is revealed at any time that I have been paid excess amount of pension 1

commutation of pension. In case the amount to be recovered i s more than the monthly

pension, I undertake to repay the same im~rnediately on demand, in lump sum. This

undertaking 1 authority i s ,irrevocable and binding upon me 1 my legal heirs 1 nominees as

well.

Yours faithfully,

Place: ........................

Date :.. ...................

......................... Signature

............................................ Name of the applicant :

Retired Employee's P. F. I Employee No. .................................................

Telephone I Mobile No ...............................................