(a) The application for pension shall be in Form-A.
(b) The sanction order shall be in Form-B.
(c) Intimation of change of address shall be in Form - C.
(d) Death intimation of the pensioner shall be in Form - D.
(e) Pension Book issued to the pensioner shall be in Form - E.
(f) Register containing details of Ulema Pensioners shall be in Form - F.
(g) Acquittance for pension paid shall be in Form - G.
LA GAZETTE DE L'ETAT [PART–II124 FORM – A APPLICATION FOR GRANT OF PENSION TO RETIRED ULEMA
1. Name in full (In block letters) :
2. Permanent address :
3. Date of birth (Proof to be attached) :
[If below 60 years, state whether he comes under relaxation category of physically handicapped along with proof thereof].
4. Qualification :
(Proof to be attached)
5. Qualifying service for pension :
(Cer t i f i ca te o f exper ience to be attached) [If below 20 years, state whether he comes under relaxation category of pysically handicapped along with proof thereof].
6. Identification marks on the body : (a) of the applicant. (b)
7. Present occupation and income from :
the occupation.
8. Other sources of income :
9. Name and address of nominee :
Place : Signature of applicant.
Date :
DECLARATION I solemnly declare that the particulars furnished in the application above are true. I agree to abide by the terms and conditions of sanction of pension under the Ulema Pension Scheme, 2011.
Signed in the presence of : Signature of applicant.
(1)
(2) Affix passport size photo 125PART–II] LA GAZETTE DE L'ETAT CERTIFICATE OF EXPERIENCE (Under Ulema Pension Scheme, 2011) This is to certify that Janab ......................................... ..................
son of Janab ............................................................. has put in a service of ...................years................ months .......................days as.............................................................................. in the Wakf Institution mentioned below :—
2. The registration details of the Wakf Institution mentioned are as follows:
3. Certified that the information furnished above are as per records of the Wakf Institution and as per my personal knowledge as Muthawalli/ President/Trustee of the Wakf Institution.
4. I undertake my personal liability for all the consequences, if the particulars furnished by me are proved as false or not genuine at a later date.
Seal of the Institution :
Signature :
Name :
Designation :
Date :
Note: The certificate should be signed only by the authorised officer/ office bearer of the Wakf Institution in which the applicant worked.
Name and address of Wakf Institution Post held Period of service and length of service From To Last pay drawn
(1) (2) (3) (4) (5) LA GAZETTE DE L'ETAT [PART–II126 FORM-B SANCTION ORDER No: Dated :
T h e a p p l i c a t i o n f o r U l e m a P e n s i o n s u b m i t t e d b y Thiru .............................................. was considered by the Sanction Committee. Thiru ................................................................. has been found eligible for sanction of Ulema Pension under the Ulema Pension Scheme, 2011.
Accordingly, he is sanctioned a monthly pension of ` 1,000 (Rupees one thousand only) with effect from ............................. .
He is directed to approach the undersigned at (office address) ................................................................. to receive his pension.
Member-Secretary (Sanction Committee).
To ...........................
...........................
...........................
———— FORM-C FORM OF CHANGE OF ADDRESS I, .................................................., a pensioner under the Ulema Pension Scheme, 2011, with Pension Order No....................... hereby inform that I have changed my address, which is furnished hereunder:
New address with name :
Place : Signature of pensioner.
Date :
127PART–II] LA GAZETTE DE L'ETAT FORM - D FORM OF DEATH INTIMATION OF PENSIONER BY HIS SPOUSE/CLOSE RELATIVE Thiru ......................................... , pensioner under the Ulema Pension Scheme, 2011 (Pension Order No. .......................... ), expired on .................................... and his death certificate is enclosed herewith.
Place : Signature of spouse/ Date : close relative.
———— ULEMA PENSION SCHEME, 2011 FORM - E PENSION BOOK (Cover Page) GOVERNMENT OF PUDUCHERRY Department of Hindu Religious Institutions and Wakf PENSION BOOK Pension No:
1. Name and address of the pensioner :
2. Father’s/ Husband’s name :
3. Sex : Male/Female
4. Date of b i r th /age as on date of :
sanction.
5. Signature /Thumb-impression of the :
pensioner.
6. Signature of the issuing authority with :
office seal.
LA GAZETTE DE L'ETAT [PART–II128 Sl.
No.
Pension No.
Name and address of the pensioner Sanction No.
and date
(1) (2) (3) (4) (5) (6) Month from which sanctioned Initial of the disbursing official FORM - F REGISTER OF ULEMA PENSIONERS UNDER THE ULEMA PENSION SCHEME, 2011 (Inner Page) Details of payment— Month for which the pension is due Date of payment Signature/Thumbimpression of the pensioner Signature of the disbursing official
(1) (2) (3) (4) 129 PART–II]LA GAZETTE DE L'ETAT U L E M A P E N S IO N S C H E M E , 2 0 1 1 F O R M - G A C Q U IT T A N C E F O R P E N S IO N P A ID T O U L E M A S Sl. No.
Pension No.
Name and address of the pensioner A p ril M a y J u n e Ju ly A u g u s t Date on which sent Date of payment Date on which sent Signature of pensioner Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner LA GAZETTE DE L'ETAT[PART–II 130 N o v e m b e r D e c e m b e r J a n u a ry F e b ru a ry M a rc h S e p te m b e r O c to b e r Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner Date on which sent Date of payment Signature of pensioner (B y o rd e r o f th e L ie u te n a n t-G o v e rn o r) R . A R U N A C H A L A M , U n d e r S e c re ta ry to G o v e rn m e n t (W a k f).
— — — — o n lin e p u b licatio n at “ h ttp ://sty a n d p tg .p u d u ch erry.g o v.in ” G o v e rn m e n t C e n tra l P re ss D ire c to ra te o f S ta tio n e ry a n d P rin tin g P u d u c h e rry -9 .