Schedule LIII-Form No.381 (New) O. C. S. (COMMUTATION OF PENSION) FORM 5 ( See rule 8 and with F. D. Resolution No.29826, dated the 9th July 1992 FORM OF NOMINATION To Head of Office (Place)................. I.................hereby authorise the person named below, under rule 8 of the Orissa Civil Services(Commutation of Pension) Rules, 1992. Name and address of thenominee Relationship with thepensioner If nominee is minor Name and address of othernominee in case the nomineeunder column (1) pre-deceases the pensioner Relationship with pensioner Date of birth if the other nominees is minor Name and address of personwho may receive thecommuted value of pensionduring the other nominee'sminority Contingency on happening ofwhich nomination Date of birth Name and address ofperson who may receivethe said commuted valueduring the nominee'sminority 1 2 3 4 5 6 7 8 9 Place....... Date ....... Signature (or name of Pen thumbsioner. impression if illiterate) and Witness : Signature .............. Name and address ............. Address : Si gnature of Head of Office Stamp Acknowledgement to be sent by the Head of Office Certified that the nomination has been received from.................... (name of pensioner) whose address is............... Place ........ Signature of Head of Office / Authorised Authority Date .........: Full Address
