COMPLETED - FP DWS IN PDF PRINTOUT FORM 16.11.25

Pensionary benefits - Family Pension (Death While in Service)

Name of the Employee

Designation

Date of Birth :

Date of entry in to service :

Date of Death :

Last Basic Pay drawn :

Dearness Pay (%) :

Recoverable Amount from Employee if any :

Dearness Allowance (DA) (%) :

House Rent Allowance (HRA) (%) :

CCA :

Earned Leave Balance :

Service History / Non-Qualifying Periods

Particulars	Days	Months	Years
a) TTR Service
b) Military service
c) Govt. Service
d) Workcharge establishment service
e) Dies non period
f) Extraordinary Leave/LWA
g) Suspension period not regularized

>> Age at the time of death, Age at the time of entry into service & Gross qualifying service

Particulars	Days	Months	Years
Date of Death	00	00	0000
(-) Date of Birth	00	00	0000
Age at the time of retirement	00	00	0000

Particulars	Days	Months	Years
Date of entry into service	00	00	0000
(-) Date of Birth	00	00	0000
Age at the time of entry into service	00	00	0000

Particulars	Days	Months	Years
Date of Death	00	00	0000
(-) Date of entry into service	00	00	0000
Gross qualifying service	00	00	0000
(+) As per KPTCL Circular k.c.o.-01/58129/2016-17/12.01.2017	00
Gross qualifying service	00	00	0000

>> Net Qualifying Service

(1) = Gross qualifying service	00	00	0000
Add:
a) 1/4th of TTR Service Maximum 3 Years	00	00	0000
b) Military service Maximum 5 Years	00	00	0000
c) Govt. Service	00	00	0000
d) Workcharge establishment service	00	00	0000
(2) = (a)+(b)+(c)+(d)	00	00	0000
(3) = (1)+(2)	00	00	0000
Less:
e) Dies non period	00	00	0000
f) Extraordinary leave/LWA > 3 Years	00	00	0000
g) Suspension period not regularized	00	00	0000
h) Boy Service	00	00	0000
(4) = (e)+(f)+(g)+(h)	00	00	0000
(5) = (3)-(4) Net Qualifying service	00	00	0000

>> Emoluments

Emoluments	=	Last Basic Pay drawn	+	Dearness Pay
	=	0.00	+	0.00
	=	0.00
Emoluments	=	Rs. 0.00

>> Death-cum-Retirement Gratuity (DCRG)

Death Gratuity	=	Emoluments2	×	Half Yearly Qualifying Service
	=	0.002	×	0
Death Gratuity	=	Rs. 0.00

>> Family Pension

Family Pension	=	Emoluments	×	30%
	=	0.00	×	30%
	=	0.00
Family Pension	=	Rs. 0.00