Application Form for payment of Pension & other Retirement Benefits to the Railway employees, option for Cashless Treatment Scheme in Emergency (CTSE)
Modified Settlement Forms to be filled by the retiring Railway servant | Option for CTSE
GOVERNMENT OF INDIA(BHARAT SARKAR)
MINISTRY OF RAILWAYS (RAIL MANTRALAYA)
(RAILWAY BOARD)
2016/F(E)III/1(1)/8
New Delhi, dated: 25.01.2019.
The GMs/PFAs
Zonal Railways/Production Units.
(As per mailing list)
Sub: Settlement Forms to be filled by the retiring Railway servant.
Attention of the Zonal Railway/Production units is invited to Board's letter of even number dated 12.11.2018 on the above subject vide which a set of settlement forms to be filled in by the retiring railway employees was circulated. The Said set of settlement forms has been modified to include the option for Cashless Treatment Scheme in Emergency (CTSE) as well.
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2. Accordingly, in partial Supersession of the letter dated 12.11.2018, a modified set of settlement forms is enclosed herewith for compliance and guidance. Other instructions contained in the letter dated 12.11.2018 will remain the same.
3. Please Acknowledge receipt.
(G. Priya Sudarsani)
Director, Finance(Estt.)
Railway Board
D.A.: As above.
Employee’s Signature
* in case option for CTSE is ‘Yes’, Annexure -IV (page 5 of 8)should also be filled.
(b) Identification Marks (i) ________________ (ii)_________________________
6. Three specimen signature, Identification Mark(s) and Fingers’ Impression of left hand of Spouse:
(b) Identification Marks (i) _____________________(ii)____________________
Signature of the Gazetted Officer
Name________________________
Designation___________________
Ruber stamp with name
of certifying authority
PAYEE’S LETTER OF AUTHORITY
2. I agree to undertake that any amount excess/wrong payment of pension if credited to my above savings bank account may be recovered or withdrawn from the said savings bank account by the public sector bank.
E-mail id ____________________________________
Permanent Address after Retirement:
____________________________________________
Annexure I | ||
Application Form for payment of Pension & other Retirement Benefits to the Railway employees (Note : Application Form to be filled up in all respect by the employee and submitted in triplicate ) | ||
I _________________________________________________Furmish below my relevant particulars and request to arrange to pay me DCRG/Gratuity, SRPF, CGEGIS & Pension and may be permitted to commute______________________&(______________________________percent) of my pension:- | ||
1. Full Name (in Block Letters) ___________________________________________ | ||
2. Fathers/Husband’s Name______________________________________________ | ||
3. Date of Birth____________________________ | 4. Date of Appointment______________________ | |
5. Designation____________________________ | 6. RUID Number___________________________ | |
7. Basic Pay _____________________________ | 8. Pay Level_______________________________ | |
9. SRPF No._____________________________ | 10. PAN No. _____________________________ | |
11. Mobile Number________________________ | 12. E-mail ld ______________________________ | |
13. Aadhaar No. __________________________ | 14. Mark of Identification_____________________________ | |
15. Religion____________________________________________________________________ | ||
16. Present/Correspondence Address with PIN Code____________________________________ _____________________________________________________________PIN__________________ | ||
17. Permanent Address with PIN Code________________________________________________ _____________________________________________________________PIN__________________ | ||
18. Details of Railway/ Directorate of Estate Quarter, if allotted ______________________________PlN_________________ | ||
19. Date of Retirement______________________ | 20. Date of start of Pension___________________ | |
21. Class of Pension : Superannuation/Voluntary etc._____________________________________ | ||
22. Details of Public Sector Bank from where pension will be drawn : | ||
(a) Savings Bank Account No. _______________ | (b) Name of Bank__________________________ | |
(c) Branch_______________________________ | (d) City_______________________ | |
(e) District_______________________________ | (f) IFSC ______________________ | |
23. Medical facility being availed at present (CGHS/RMA)_________________________________ | ||
24. Medical Card (s) No._________________________________________________________ | ||
25. Details of Military /Other Service, if any | ||
(a) Total Period of Military Service | From ______________________to______________ | |
(b) Amount of Gratuity received for the Military Service___________________________________ | ||
(c) PPO No. & Date of Issue (attach a self attested Photocopy of)____________________________ | ||
Note: Please attach : (A) a cancelled cheque, issued for Bank Account mentioned above at S. No.22. | ||
(B) self attested photocopies of PAN, Aadhaar and Medical Cards. | ||
Place_____________________ | ||
Date______________________ | ||
Employee's Signature |
Annexure II
DECLARATION FOR NON ACCEPTING COMMERCIAL EMPLOYMENT
I note that I cannot accept any commercial employment before the expiry of one year from the date of retirement, or any employment under a government outside India at any time without prior sanction of the President of India. I cannot seek employment as contractor for or in connection with the execution of public works (Whether on the Railways, or under P.W.D. or Defence Forces) or employment of such contractors, within one year of my retirement, without the prior permission of the President of India.
DECLARATION FOR NON RECEIPT OF PENSIONARY BENEFITS
I hereby declare that I have neither applied for nor received any ordinary Gratuity/Pension/Death-cum-retirement Gratuity in respect of any portion of the service included in this application and in respect of which ordinary Gratuity/Pension/Death-cum-Gratuity is claimed herein, nor shall I submit an application hereafter without quoting a reference to this application and to the orders which may be passed thereon.
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I am in occupation of Railway / Directorate of Estates’ (DOE) HOUSE No__________________________________________on my retirement form Railway Service, I agree to withhold Death-cum-Retirement gratuity as per extant orders till such time, I vacate the Railway Quarter/DOE accommodation.
Employee’s Signature
1*' Witness Signature :________________________
Name ______________________________________
Designation_________________________________
RUID No. __________________________________
2nd Witness Signature : ______________________
Name______________________________________
Name______________________________________
Designation ________________________________
RUID No. _________________________________
Note : After vacating the government accommodation, employee may apply for refund of withheld gratuity in prescribed proforma, along with all required documents. In case of Directorate of Estates’ accommodation, the retiring employee has to apply online for obtaining the "No Demand Certificate".
Annuxure III
DETAILS OF FAMILY MEMBERS
1. Name and Designation of the employee
__________________________________
2. Father’s/Husband’s Name
__________________________________
Affix Joint Photo(to be duly signed across by self and spouse) | Affix Employee's Photo |
3. Details of all family members :-
S. No. | Name (in Block Letters) | Relationship with Railway Servant | Date of Birth (attach a photocopy of valid document as proof) | Aadhaar No.(attach a photocopy of Aadhaar Card) |
S. No. | Date of marriage in case of married children | Name of spouse of married child | Indicate the nature of handicap (mental/physical) , if any, of the child and whether it is permanent or temporary | Remarks/Any other information |
Employee’s Signature
4. For taking option under CTSE:-
RELHS | CTSE (Only if option for RELHS is given) | Amount to be deducted from pay |
*Yes/No | Yes/No | Rs..........(As per grade pay and entitlement for RELHS including cost of cards) |
5. Three specimen signature, Identification Mark(s) and Fingers’ Impression of left hand of the Railway Employee :
(a) Specimen Signature
(b) Identification Marks (i) ________________ (ii)_________________________
(c) Fingers’ Impression of Left Hand :-
Thumb | Index Finger | Middle Finger | Ring Finger | Little Finger |
6. Three specimen signature, Identification Mark(s) and Fingers’ Impression of left hand of Spouse:
(a) Specimen Signature
(b) Identification Marks (i) _____________________(ii)____________________
(c) Fingers’ impression of Left Hand :-
Thumb | Index Finger | Middle Finger | Ring Finger | Little Finger |
PLACE _________________
Date________________________
Employee’s Signature__________
Date________________________
Employee’s Signature__________
Certified that the joint photograph pasted at pre-page (Column 2) is of Smt. &_____________Shri_______________________________and the information declared from Column No. 1 to 5 by the Railway employee are believed to be true and both persons signed and put fingers' impressions before me.
Signature of the Gazetted Officer
Name________________________
Designation___________________
Ruber stamp with name
of certifying authority
Annexure - IV
7. Declaration to be taken from RELHS members on becoming a member of CTSE.
1. I hereby apply to become a member of the Cashless Treatment Scheme in Emergency by Railway. I request Indian Railway to issue individual CTSE photo identify card(s) for following members, whose name(s) feature in RELHS card, of my family.
S.No. | Name | Relation | DOB Dd/mm/yyyy | Aadhaar Number | Special feature of dependent |
Self | |||||
I hereby undertake to inform the Sr. DPO/Dy.CPO concerned either through the designated website or in writing. Whenever any of my above mentioned family members become ineligible under RELHS and surrender his/her card.
2. I have been made aware that this CTSE card entitles me for treatment in private hospitals ONLY AT THE TIME OF EMERGENCY. In routine illness or any illness which does not require immediate intervention/investigation, I shall continue to report to my authorised medical officer in Railway.
3. I have been explained that under CTSE scheme that if the disease/condition turns out to be non-emergency, then I will be referred to Railway hospital and if I wish to continue then I will bear the cost of treatment and will not claim reimbursement for same. If same is declared as emergency by concerned Railway medical officer, then the whole bill amount shall be paid by the railway.
4. I hereby declare that I shall abide by the rules of the CTSE scheme in letter and spirit.
5. I undertake that I shall not allow others to misuse the CTSE cards issued to me and my family members by way of if for obtaining treatment for a non-bonafied person. I further undertake that I shall not allow other family members to misuse the cards by way of utilising it for non-emergency disease treatment at Private empanelled Hospital. Any misuse is liable to disqualify tha card holder from menbership of the CTSE scheme, with forfeiture of the initially deposited amount.
6. In case of loss of CTSE cards, I shall lodge a complaint with police and inform the Sr. DPO.Dy. CPO of concerned either through this website or in writing for issue of new card to me on deposition of CTSE card Making Charges Prevalent at that time.
7. I hereby declare that I have been explained and I understand that Cashless treatment under CTSE Scheme shall be available only in Railway empanelled Hospitals, I shall have to pay the entire bill myself and shall claim reimbursement later on as per extant rules.
Signature of the Employee
6. In case of loss of CTSE cards, I shall lodge a complaint with police and inform the Sr. DPO.Dy. CPO of concerned either through this website or in writing for issue of new card to me on deposition of CTSE card Making Charges Prevalent at that time.
7. I hereby declare that I have been explained and I understand that Cashless treatment under CTSE Scheme shall be available only in Railway empanelled Hospitals, I shall have to pay the entire bill myself and shall claim reimbursement later on as per extant rules.
Signature of the Employee
Name:_____________________
Contact No_________________
E-mail:____________________
Annexure V
(Part to be sent to M/s UTITSL for marks CTSE card)
1. Name of Employee
2. Date of Birth
3. Last Pay Drawn
4. Date of Retirement
5. PPO no.
6. Entitlement of Card (General/Semi-Private/Private)
7. Beneficiary details including self:-
S.No. | Name | DOB Dd/mm/yyyy | Relationship with beneficiary | Photo |
(To add or reduce above rows as required)
The required amount including the cost of card has been received by Railways. M/s UTIITSL to make the CTSE card for the applicant.
Authorised
Personnel Officer
Date
Office
(Details of the above information to be filled online in the website -https://Awww.railemedical.utiitsl.com.
PAYEE’S LETTER OF AUTHORITY
I request that my Provident Fund and Death-cum-Retirement Gratuity/Compassionate gratuity/Leave Encashment /SRPF /CGEGIS /Pension Commutation amount may be remitted to me through ECS/RTGS/NEFT.
I agree that the remittance made in the aforesaid manner shall be at my sole risk and shall be a complete discharge of Government from all liability on the amount being remitted by ECS/NEFT/RTGS/Money order/Cheque/Bank Draft forwarded by registered post, as the case may be.
PRE-RECEIPT
Received from Pay & Accounts Officer, _____________________a sum of ____________________ RS_______________________as full and final settlement of my claim to Provident Fund Amounts/Gratuity/Compassionate gratuity/Leave Encashment/GIS/Pension on Commutation Value :
Revenue Stamp (to be duly signed across by the employee) | Signature of Employee |
Signed before me.
Signature of Witness :______________________
Name ___________________________________
Designation _____________________________
RUID No. _______________________________
Date____________________________
Signature of Head of office*
_______________________
(Stamp) ___________________
* Head of Office, means a gazetted officer whom the appointing authority may, by order declare as Head of office and includes such other authority or person whom the appointing authority may specify in the like manner.
Annexure- VII
LETTER OF AUTHORITY UNDERTAKING FOR DRAWAL OF PENSION THROUGH PUBLIC SECTOR BANK WITH PERMANENT ADDRESS & MODE OF PAYMENT
1. I hereby authorize Manager, ________________________________ Bank to receive my monthly pension and credit the same to my saving bank account (pension) on the first working day of every month as per particulars given:-
Amount of pension per month at the time of retirement :
RS _________________________________(Rupees______________________________________)
RS _________________________________(Rupees______________________________________)
2. I agree to undertake that any amount excess/wrong payment of pension if credited to my above savings bank account may be recovered or withdrawn from the said savings bank account by the public sector bank.
3. The authority shall remain in force until due notice in writing is given by me.
1st Witness Signature : _______________________
Name _____________________________
Empioyee’s Signature : _________________________
Designation _________________________
Name _______________________________________
RUID No. ___________________________
Designation __________________________________
RUID No ____________________________________
Mobile No ___________________________________
E-mail id ____________________________________
Permanent Address after Retirement:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
PIN Code_____________________________________
____________________________________________
____________________________________________
PIN Code_____________________________________
2 Witness Signature: ______________________
Name ___________________________________
Designation ___________________
RUID No. _________________________________
Date _____________________________
COMMENTS