1. Name ………………………………………………………………………………………………

2. Designation ………………………………………………………………………………………

3. Date of Birth ………………………………………

4. Date of entry in the Government service…………………………………………………………

5. Date of retirement …………………………………………………………………………

6. Length of qualifying service reckoned for pension /gratuity (as indicated in PPO) ………………………..

7.Emoluments drawn during the last 10 months………………………………………………………………

8.  (1) Average emoluments for pension (as indicated in PPO)……………………………………………….

    (2) Pension admissible ………………………………………………………………………………

                      Calculations to be shown as follows: -

                                Average Emoluments    _X    Qualifying Service
                                            2                                       66

9. (1) Emoluments for gratuity (as indicated in PPO)……………………………………………………….

    (2) Retirement gratuity admissible. ………………………………………………………………………

                      Calculations to be shown as follows: -

                                 Emoluments      _X          Qualifying Service
                                        4

10. (1) Emoluments for Family Pension (as indicated in PPO) ……………………………………………….

      (2) Family Pension admissible …………………………………………………………………………….

           Calculations to be shown as follows: -

           (a) Ordinary Family Pension: -

                      Pay last drawn    x     Prescribed % subject to prescribed minimum and maximum

           (b) Enhanced Family Pension:

                 Family Pension at ordinary rate as at:

                       (a)  Above  x 2  ( subject to prescribed minimum and maximum as per Rule 54.)

Countersigned

Head of Office

PAO