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Personal Details
Pensioner Name : Mr. SUBHRA KANTI BISWAS

Gender : Male

PAN : XXXXXX023C

Type of Retirement : BSNL Voluntary Retirement Scheme 2019

Ministry : Ministry of Communications

Department: Department of Office: Oo PGM TRANSMISSION

Telecommunications under CGM CTD

Division : TRANSMISSION Designation: SDE

Emp. Code : Date of Birth : 28/10/1961

Date of Appointment : 04/04/1985 Date of SuperAnnuation : 31/10/2021

Date of Retirement : 31/01/2020 Father's/Husband's Name : JAHAR LAL BISWAS

Mothers Name:

I consent the use of my Aadhaar number for the purpose of establishing the identity
and generation of Annual Digital Life Certificate for Pension.
The Aadhaar Number will be shared with O/o CCA, DOT( PDA). :

Email : [email protected] Alternate Email:

Mobile No. : 9433000248 Height : 168

Blood Group : O+

Aadhaar No. : XXXX-XXXX-2262 Is Active:

Present Address
State : WEST BENGAL

District : 24 PARAGANAS NORTH

City : KOLKATA

Address : URSA COOPERATIVE HOUSING SOCIETY LIMITED FLAT NO 1B CE 1 C 199 PREMISES NO 03 177 ACTION AREA 1 BEHIND AXIS MALL NEWTOWN KOLKATA 700156

Pincode : 700156

Permanent Address

State : WEST BENGAL

District : 24 PARAGANAS NORTH

City : KOLKATA

Address : URSA COOPERATIVE HOUSING SOCIETY LIMITED FLAT NO 1B CE 1 C 199 PREMISES NO 03 177 ACTION AREA 1 BEHIND AXIS MALL NEWTOWN KOLKATA 700156

Pincode : 700156

Personal Identification Marks : 1. SCAR MARK ON THE RIGHT BACK OPRTION 2. NIL

Indicate whether the family

pension is admisable from any
other source:

Signature Joint Photograph

Commutation & Fixed Medical Allowance

Percentage of superannuation 0%
pension desired to be
commuted(upto 40%)

Family Member Details

Name of the family member Date of birth Relation With Govt. Servant Marital Status Image

SHELLEY BISWAS 07/01/1971 Wife Married

SHEMONTI BISWAS 08/01/1999 Daughter Unmarried

Nomination Form 1

Nominee Nomination %age share to Alternate Nominee(If Contingencies on happening of which nomination shall become
S.No.
Name For be paid any) invalid

1 SHELLEY Gratuity 100 SHEMONTI DIVORCE AND INSANITY

BISWAS

2 SHELLEY GPF 100 SHEMONTI DIVORCE AND INSANITY

BISWAS

Nomination Form A

Nominee %age share to Alternate Nominee(If Contingencies on happening of which nomination shall
S.No. Nomination For
Name be paid any) become invalid
 Nominee %age share to Alternate Nominee(If Contingencies on happening of which nomination shall
S.No. Nomination For
Name be paid any) become invalid

1 SHELLEY Arrears Of Pension 100 SHEMONTI BISWAS DIVORCE AND INSANITY

BISWAS

2 SHELLEY Commuted Value Of 100 SHEMONTI BISWAS DIVORCE AND INSANITY

BISWAS Pension

 
Bank Details

Bank Name : STATE BANK OF INDIA IFSC Code :

SBIN0014528

Account Number(Latest) : 38961142985 Type of Bank Account

Joint account,either or survivor, with the spouse

Check List Of Documents To Be Submitted Along With FORM-5

S.No. Description of document to be enclosed Whether Enclosed

1 (A) Two specimen signatures (to be furnished in a separate sheet) Yes

Additional information (Only in case of an illiterate or disabled Government servant.):- Two slips each bearing the left hand thumb and finger
impressions duly attested may be furnished by a person who is not literate and cannot sign his name. If such a Government servant on
1 (B) account of physical disability is unable to give left hand thumb and finger impressions he may give thumb and finger impressions of the right N.A.
hand. Where a Government servant has lost both the hands, he may give his toe impressions. Impressions should be duly attested by a
Gazetted Government servant.

Three copies of passport size joint photograph with wife or husband. Where it is not possible for a Government servant to submit a
photograph with his wife or her husband, he or she may submit separate photographs. The photographs shall be attested by the Head of
2 Yes
Office. Three copies of passport size photograph of disabled child/siblings/dependent parents, if applicable. (To be attested by the Head of
Office)

3 Details of the family in Form 3. Yes

4 Undertaking for refunding any excess payment made by the Pension Disbursement Account Yes

5 Nomination for gratuity, CGEGIS and GPF in Common Nomination Form Yes

6 Nomination for arrears of pension and commuted value of pension (if applied for commutation of pension) in Common Nomination Form Yes

7 Declaration for non-employment after retirement in case of Gr. “A” pensioner N.A.

8 Mandate Form along with cancelled cheque for E-Payment(details already filled in Bank details) Yes

Undertaking in Form 26, for those who served in Security-related or Intelligence Organisations referred to in rule 8 of the CCS (Pension)
9 N.A.
Rules, 1972

10 Photocopy of PAN & Aadhaar Card attached. Yes