Modified Settlement Forms to be filled by the retiring Railway servant

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.

		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______________________________________

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)

* in case option for CTSE is ‘Yes’, Annexure -IV (page 5 of 8)should also be filled.

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)_________________________

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)____________________

Thumb	Index Finger	Middle Finger	Ring Finger	Little Finger

PLACE _________________

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

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______________________________________)

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_____________________________________

2 Witness Signature: ______________________

Name ___________________________________

Designation ___________________

RUID No. _________________________________

Date _____________________________

Place __________________________