FORM B

Nomination for Life Time Arrears

(G.O. 562 Fin 26.06.1987)

To
The Pension Disbursing Authority
Head of Office / Name of Bank / Treasury / Post Office /
Accounts Office - 
Place -

I  _______________________________(Name of the Pensioner in capital letters) hereby make the following alternative nomination in cancellation of the previous nomination  made 

Named below for receiving my life time arrears of pension

Name and Address of the Nominee

Relationship with Pensioner

Date

of

Birth

If Nominee is minor the name and address person who may receive the said pension during the nominees minority

Name and address of other nominee  in case the nominee in (i) pre deceases the pensioner

Relationship

with

pensioner

Date of birth if the other nominee is  minor

Name and address of the person who may receive the pension during the other nominees minority

Contingency on the  happening of which nomination becomes invalid

Place _________________ 

Date __________________

Signature or Thumb impression if illiterate
and name of the  pensioner

Address

Witness Signature

Name and Address

Signature of Pension Disbursing Authority / Head of Office

  ( Acknowledgement to be sent by the Pension Disbursing Authority / Head of Office )

Certified that application (Form B)  has been received from the  _______________________ whose address is given in Form A has been cancelled and returned to him.

Place:

Date:

Signature of Pension  disbursing authority 

PO/Bank/Treasury with full address