Form containing life certificate, letter of authority, etc. In the case of indian military pensioners not able to appear in person to receive payment I.A.F.A. – 409

 

 

1. I have received Rs. ------ P. ----------- being my pension for --------------------------------

(Month & Year)

 

2. Please hand it over to --------------------------------------------------------------

(Nominee’s Name, Rank or Designation)

whose specimen signature/left hand thumb Impression is given below.

 

 

 

3. Signature or left-hand thumb impression                 of Pension. (On One Rupee stamp if the                  amount exceeds Rs. 500. Non-commissioned Officers and men and their heirs are exempted.)

 

Specimen Signature Left-hand                 Station ----------------------

Thumb impression of the Nominee                 Dated  -----------------------

 

DECLARATION (A)

 

I declare that I have not received pay or allowances for serving in (a) any military capacity, (b) on re-enrolment or re attestation during the period for which pension is claimed on the basis of this certificate or during any period since the last declaration was given by me (see notes 1 to 3 and 5 below)

 

---------------------------

 

Signature or left-hand thumb impression of the pensioner

 

Station -------------------

Dated  -------------------

DECLARATION (B)

 

I further declare that except the pension specified in the certificate, I am neither in receipt of any family pension nor any service or disability pension in respect of previous service in any regiment or other Military formation or any other Department, Civil or Military under Government of India or any Local Government (see Notes 1 to 3 below)

 

 

---------------------------

 

Signature or left-hand thumb impression of the pensioner

 

 

Station -------------------

Dated  -------------------

DECLARATION (C)

 

I declare that I am in receipt of a second pension, full particulars of which are given below

 

1.Nature of Pension------------------------------

2. Rate of Pension---------------------------------

3.Date of commencement of Pension ------------------

4.Service or other particulars in respect of which the second pension was granted -------------------------------

 

5.   Authority sanctioning the second Pension ---------

---------------------------

 

Signature or left-hand thumb impression of the pensioner

Station -------------------

Dated  -------------------

 

 

NOTE: 1.            When a pensioner is neither re-employed nor in receipt of a second pension he should sign at the place provided for the purpose underneath the Declaration ‘A’ & ‘B’.

When a Pensioner is re-employed, he would sign at the place provided for the purpose underneath the Declaration ‘B’ as well as I.A.F.A. 379, which will be in lieu of Declaration ’A’.

 

When a Pensioner is in receipt of a second pension, he should sign at the place provided for the purpose underneath the Declaration ‘A’, further information regarding the second pension should be recorded in Declaration ‘C’.

 

Female pensioners applying for pensions whose pensions are terminable by re-marriage, or marriage, should render a widowhood or non-marriage certificate in addition.

 

Declaration ‘A’ is not applicable in the case of a female family pensioner.

 

FOR USE BY THE PENSIONER’S NOMINEE

 

I have received Rs. ------------------ being pension cf -------------------------------------------------------------------- (Descriptive No. Rank and Name of the Pensioner) to be handed over to him/her.

 

 

 

Station --------------------                  Nominee’s Signature ------------------------

Dated  ---------------------                 Rank or Designation  -----------------------

 

 

FOR USE BY THE ATTESTING OFFICER

 

I hereby certify that pensioner -------------------------------------------------

(Descriptive No.  Rank and Name)

late of the ------------------------------------------------------------------------

(Corps. Department or Office)

Or pensioner’s heir or heirs --------------------------------------------------------

(Descriptive No. and Name)

being widow or children of late -------------------------------------------------- (Rank, Name and Corps or Office)

is or are alive on this date and I his/her signature or left-hand  thumb impression on this form have been taken in my presence.

 

 

Station --------------------                  Nominee’s Signature ------------------------

Dated  ---------------------                 Rank or Designation  -----------------------

 

 

Signature or left-hand thumb

impression of the pensioner

 

 

NOTE: 1.            Life Certificate should be obtained on or after the last day of the month or quarter for which pension is due.

 

In the case of severely wounded and infirm Indian Military pensioners and female pensioners who are not accustomed to appear in public, a life certificate from a responsible Govt.  Officer or by some other well-known and trustworthy person will be accepted. A certificate issued by a Junior Commissioned Officer/Junior Commissioned officer pensioner, a retired Gazetted officer pensioner, a Sub- Inspector of Police, a Sub- Postmaster, a Tehsildar, a Village Head Man, a Patti Patwari (in the case of Garhwali pensioners) or the head of the Village Panchayat, who is acquainted with the pensioner will also be accepted by the Pension Disbursing Officer, provided he has no reason to doubt the veracity of such a Certificate.

 

In the case of Gorkha pensioner living in Nepal who is physically unable to apply for his pension in person, payment may be made through a Pension Disbursing Officer in India or under arrangements by the Indian Embassy Nepal, to a representative who produces a life certificate signed by other two male military pensioners if below J.C.O. rank or by a pension of J.C.O. rank acquainted with the pensioner.

 

In the case of pensioners residing in Sikkim and Bhutan who are physically unable to draw their pensions in person, payment may be made by the Political Officer there, through a representative in accordance with procedure indicated in Note 3 above.