(i) I am not holding the elected office of the President or the Vice-President or the Office of the Governor of any State or the Administrator of any Union Territory;
(ii) I am not a member of the council of State (Rajya Sabha) or House of the People (Lok Sabha) or any Legislative Assembly of State or Union Territory or any Legislative Council of a State or the Metropolitan Council of Delhi constituted under section 3 of Delhi Administration Act, 1966;
(iii) I am not employed on a salary under the Central Government or any State Government or any Corporation owned or controlled by the Central Government or any State Government or any Local Authority or I am not otherwise entitled to get any remuneration from such Government or Corporation or Local Authority;
(iv) I am not in receipt of pension from any Political/ Military/Civil Services;
(75)
(v) I am holding the office of the..........................or Member of.........................................................or employed as...................... in...........................and the total remuneration received by me is Rs..............P.M. (A certificate from the competent authority to be attached);
(vi) I am in receipt of Rs..............as Political/Military/Civil pension being drawn from...................................(A certificate from the competent authority to be attached) NAME IN BLOCK LETTERS Yours faithfully ........................................ ( ) Place :
Date :
Rajasthan Legislative Assembly Secretariat Certified that Shri/Shrimati/Kumari.............................................
(IN BLOCK LETTERS) served as a member of Rajasthan Legislative Assembly during the following period :— From...................................to...........................
From...................................to...........................
From...................................to...........................
Principal Secretary, Rajasthan Legislative Assembly Secretariat.
(76) Certified that Shri/Smt./Kumari...........................................
(IN BLOCK LETTERS) served as a member of the Lok Sabha during the following period:— From...................................to...........................
From...................................to...........................
From...................................to...........................
From...................................to...........................
Senior Table Officer, Lok Sabha Secretariat.
Certified that Shri/Smt./Kumari........................................
(IN BLOCK LETTERS) served as a member of the Rajya Sabha during the following period:— From...................................to...........................
From...................................to...........................
From...................................to...........................
From...................................to...........................
Senior Table Officer, Rajya Sabha Secretariat.
Rajasthan Legislative Assembly Secretariat No........................... Jaipur, dated the...........................
Till further notice, and on the expiry of every month, be pleased to pay to Shri/Smt./Kumari............................................. the sum of Rs..........................being the amount of pension under proviso to Section (2) of the Rajasthan Legislative Assembly (Officers and Members Emoluments and Pension) Act, 1956 as amended, as per details given below :— Pension due under Section-4 (a) Rs................................
Less : remuneration/pension Rs................................
Net pension payable Rs................................
The payment should commence from...........................
and payment be made upto........................................
Signature............................
Designation.........................
(77) (FORM-2) Pension Payment Order Disburser's Portion Debitable to State Government :— Head of account :— Major head :— Minor head :— VOTED
1. Name of the Pensioner...................
[under proviso of rule (2)]
2. Residential address.........................
3. Village and Tehsil & Distt...............
4. Distinguishing mark (Mark of Identification) of the Pensioner..................
5. Class of pension-Pension under the Rajasthan Legislative Assembly (Officers & Members Emoluments and Pension) Act, 1956, as amended.
6. Amount of monthly pension Rs................(Rupees in words) Signature of Pensioner
7. Date of commencement from...................to......................
payment may be made.
8. Office and place of payment............................................
Principal Secretary, Rajasthan Legislative Assembly, Jaipur.
Date.....................
Place....................
PHOTOGRAPH of the Ex-MLA duly attested by Competent Officer
(78) Amount of pension Rs...........(Rupees in words) every separate payment is to be recorded below by the Disbursing Officer.
Month for which 19 19 19 19 pension is due Date of Disbursing Date of Disbursing payment Officer Payment Officer (Signature) March April May June July August September October November December January February Date :
Place :
Signature.......................
Address.........................
...................................
...................................
(79) [FORM-3] Declaration (To be furnished by ex-member of Rajasthan Legislative Assembly with his first pension bill and thereafter twice a year i.e. in the months of May and November) I declared that : —
1. Since 14.12.1976 or....................................(here in case of second and subsequent declaration mention the date of the last declaration), I........................had been elected/nominated/appointed as..........................from............................to.....................on a remuneration/salary of Rs.....................p.m.
2. I......................................am/was not elected in the office of the President/Vice President or appointed to the office of the Governor of any State or Administrator of any Union Territory, or
3. I.........................................am/was not a member of Council of States (Rajya Sabha) or House of the People (Lok Sabha) or any Legislative Assembly or Legislative Council of a State or Metropolitan Council of Delhi constituted under section 3 of Delhi Administration Act, 1966; or
4. I.......................................am/was not employed on salary under the Central Government or any State Government or any Corporation owned or controlled by the Central Government or any State Government or any Local Authority or I............am/was not otherwise entitled to any remuneration from such Government or Corporation or Local Authority; or
5. I......................am/was not in receipt of any pension from Central Government/State Government or any Local Authority Corporation owned or controlled by the Central Government or any State Government.
(80) OR
(i) I........................am/was holding the office of.................
.........................or member of............................or employed as...........................in.......................................and the total remuneration received by me is Rs............................
(ii) I..............................am/was in receipt of Rs.................
as pension drawing from............................Station......................
Signature............................
Date : Address..............................
........................................
(81) FORM-4 Government of Rajasthan Pension Bill Not exceeding Rs.....................................p.m.
FAMILY Pension Payment Order No........................................
Memo : It is requested that the form may be used for submission of next bill.
District Head of Account Voucher No...............of list of payment for.............
20....................
Received the amount of pension due to me for the month of
20.....................as.......................
Less : Income Tax............................
Net Rs..............................(Rupees in words............................)
Place.........................
Dated........................
Pensioner's residential address.........................
............................Received Payment Stamp Pensioner Identified by me Signature Designation or address Certificate to be given in case of non-attendance in person (except in case in which such certificates are not required under any rule or order), Certified that I have seen the Pensioner, that he/she is alive on this date and that the bill has been signed by him/her.
Date.................. Name..............................
Designation.......................
(82) Endorsement to be signed by the Pensioner Please pay to.............................................
Rs..........................................
Pensioner For use in Treasury ..................................Bank/Treasury pay Rupees......................
(In words)............................................................................
Incorporated in Account...........................................................
Accountant Dated Treasury or Sub-Treasury Officer Payee's Receipt Received Payment Signature of Messenger or Agent Identified by me Signature....................................
Designation/Address......................
...............................................
...............................................
For Bank/Treasury Paid Rupees...............................(in words)..............................
Bank/Treasury For use in the office of R.L.A.
Admitted Rs................................(in words) Objects to Rupees.....................................
Auditor Superintendent Secretary, [No. F.7(1)Sansad/77] By Order of the Governor, Ranvir Sahay Verma Secretary to the Government.