Option forms for pention

DB/HO/PN/1079 /2010 September 3, 2010
To,
The All the Departmental Heads
Regional Managers
Dena Bank
Dear Sir
Re: Extending another Option-
Prescribed Option Forms to be filled in by the employees/ex-employees of
the Bank
We refer to Head Office Circular No. 179/24/2010-11 dated 30.08.2010
regarding the captioned matter.
In order that the various option forms applicable to each category of
employee/ex-employee are easily distinguished the PF/GF & Pension Fund
Department, Head Office, Mumbai has suitably given colour to different option
forms as under:
a) Annexure-I : ( White Colour) Option Form to be filled in by the employees who
are in the service of the bank prior to 29th September , 1995 and continue to be in
the service of the bank on the date settlement i.e., 27th April, 2010 including
employees who have retired/retiring after 27/04/2010.
b) Annexure-II : ( Yellow Colour) Option Form to be filled in by the employees who
were in service of the bank prior to 29th September , 1995 and retired after the date
and prior to the date of the settlement dated 27th April, 2010.
c) Annexure III : ( Blue Colour) Option Form to be filled in by the employees who
were in service of the bank prior to 29th September, 1995 and retired under VRS
2000 after putting minimum period of 15 years of service.
d) Annexure-IV : ( Pink Colour) Option Form to be filled in by the family of those
who were in service of the bank prior to 29th September, 1995 but retired on
attaining superannuation/retired under VRS 2000 and subsequently expired, or
expired while in service, before the date of Settlement / Joint Note dated
27.04.2010.
e) Annexure-V : ( Green Colour) Option Form to be filled in by the family of those
who were in service of the bank prior to 29th September, 1995 but retired
subsequently and expired, or expired while in service, after the date of
Settlement / Joint Note dated 27.04.2010.
We are sending herewith 20 forms of each Option and request the concerned
Departmental Head/ Regional Offices to obtain Photo Copies of the same in the
same colour preferably and send to their respective branches/employees/ex-
employees / family of employees/ ex-employees in sufficient numbers to enable
all the employees/ex-employees/ family of employees/ ex-employees
immediately.
Please acknowledge receipt and do the needful in the matter.
Yours faithfully
Hon. Secretary & Chief Manager
PF/GF/ & Pension Fund Department

ANNEXURE- I ( WHITE COLOUR)
( EXISTING EMPLOYEES TO SUBMIT FOUR COPIES & RETIREE FIVE COPIES) )
[Option Form to be filled in by the employees who are in the service of the bank prior to
29th September , 1995 and continue to be in the service of the bank on the date settlement
i.e., 27th April, 2010 including employees who have retired/retiring after 27/04/2010 ]
(Instruction given for filling in the forms have to be strictly followed)
To
The Asst. General Manager (HRM)
Dena Bank,
Head Office,
MUMBAI- 400 051.
I hereby declare that I have read and understood the terms of Settlement/ Joint Note dated
27.04.2010 for extending another option to join Pension Scheme. I have understood the terms of
the Settlement / Joint Note have been arrived at on the basis of the Unions/ Associations offering
to contribute 30 % of the initial funding gap assessed for extending another option for joining the
pension scheme. I am agreeable to the said contribution of 30 % towards the initial funding gap
and hereby voluntarily opt to become a member of the Bank's Pension Scheme as per the
provisions of the said Settlement / Joint Note and to cease to be a member of Contributory
Provident Fund Scheme and irrevocably authorize the Bank/ Trustees of the Contributory
Provident Fund to transfer the entire contribution of the bank along with entire interest accrued
thereon to the credit of Pension Fund to be created for this purpose. I also authorize the bank to
transfer to the pension fund an amount equal to 2.8 times of my revised pay for the month of
November 2007 representing my share in the 30 % contribution mentioned above from the
arrears payable to me on account of wage revision in terms of Bipartite Settlement / Joint Note
dated 27.04.2010.
I desire to commute 1/3rd or ........................Part of the pension / I do not desire to commute any
part of the pension ( Strike out whichever is not applicable ). [TO BE DECLARED ONLY BY
THOSE EMPLOYEES RETIRED / RETIRING AFTER 27th April, 2010. ]
1 Name in Full : Shri/Smt./Kumari (Delete
whichever is not applicable)
2 P.F No.
3 Designation
4. Branch/Department/Office
[**Write dates in the order day (DD), month
(MM) and year (Y
5 Date of Birth
6 Date of Joining the Bank
7 Date of retirement
8 Present residential address
Address 1
Address 2
City
Pin Code
9 Details of Bank’s Contribution and Interest.
(including any such payment subsequent to
retirement settlement. Please enclose photo copies
of the documents in support of the above )
( APPLICABLE IN CASE OF RETIREES AFTER
27/04/2010)
10 Details of 2.8 times of Basic Pay components
of revised pay for November,2007 contributed
towards Pension Fund Gap
( APPLICABLE IN CASE OF /EMPLOYEES AS ON
27/04/2010/RETIREES AFTER 27/04/2010)
…2

::2::
STATEMENT OF SALARY DRAWN BY THE RETIREE FOR THE LAST 10 MONTHS PERIOD PRIOR TO
THE DATE OF RETIREMENT
(WHEREVER FULL SALARY DRAWN BY THE RETIREE)
YEAR &
MONTH
BASIC
PAY
(PAID)
SPL. PAY F.P.P. P.Q.P. OTHER IF
ANY
( viz.
Officiating
Allowance,
etc)
TOTAL
1
2
3
4
5
6
7
8
9
10
TOTAL
F.P.P. & P.Q.P. - FURNISH INCREMENT COMPONENENT ONLY (i.e. Without D.A.)
TOTAL NO. OF DAYS ON LOSS OF
PAY DURING THE ENTIRE SERVICE
OF THE RETIRED EMPLOYEE
SUSPENDED & PUNISHMENT
AWARDED DURING THE ENTIRE
SERVICE OF THE RETD. EMPLOYEE
Date:
Place : SIGNATURE OF THE APPLICANT
Note :
1) Additions/alterations in the text of the above form will render the option invalid.
2) Blanks in the form have to be preferably typed, ensuring that all copies are legible.
Alternatively the blanks may filled in by hand in Block letters without the use of carbon
paper.
3) Signature or Thumb Impression should be duly attested by the Branch Manager
4) Pension Application & Commutation application will be required to be filled in
subsequently by all Pension Optees.
----------------------------------------------------------------------------------------------------------------------------
FOR BRANCH/ OFFICE USE ONLY
Certified that we have recovered 2.8 times of basic pay components of revised pay for
November,2007 Rs.
(Rupees ..........................................................................................................
only) from Mr./ Ms.........................................................................(PF No..................................) and
date of credit to Suspense Receipt Account - Contribution towards Pension Gap
The above particulars declared by the applicant are required to be checked by going
through the employees personal file/service records available at the Branch level.)
Signature
Name in Full
Designation
Branch / Office
PA No.
( To be attested by the Branch Manager/Departmental Head (holding Power of Attorney number
with official seal after Verification of information furnished in the option form)

ANNEXURE- II ( YELLOW COLOUR)
( RETIREE TO SUBMIT FIVE COPIES) )
[Option Form to be filled in by the employees who were in service of the bank prior to 29th
September , 1995 and retired after the date and prior to the date of the settlement dated
27th April, 2010]
Dena Bank,
Head Office,
MUMBAI- 400 051.
27.04.2010 for extending another option to join Pension Scheme. I have understood that the
terms of the Settlement / Joint Note have been arrived at on the basis of the Unions/
Associations offering to contribute 30 % of the initial funding gap assessed for extending another
option for joining the pension scheme. I am agreeable to the said contribution of 30 % towards
the funding gap and hereby voluntarily opt for Bank's Pension Scheme as per the provisions of
the said Settlement / Joint Note . I undertake to refund the Bank's contribution to Provident Fund
together with accrued interest thereon paid to me on my retirement plus an amount equal to 56 %
of the bank's contribution to Provident Fund with interest received at the time of retirement being
30% contribution towards the initial funding gap in terms of Joint Note dated. 27.04.2010 and the
Settlement dated 27.04.2010.
I desire to commute 1/3 rd or ........................Part of the pension / I do not desire to commute any
part of the pension ( Strike out whichever is not applicable ). [ TO BE DECLARED ONLY BY
THOSE EMPLOYEES WHO WERE IN SERVICE OF THE BANK PRIOR TO 29th
SEPTEMBER, 1995 AND RETIRED AFTER THE DATE AND PRIOR TO THE DATE OF THE
SETTLEMENT DATED 27th April, 2010. ]
Note : No medical examination shall be necessary if the application for commutation is
made within one year from the date of retirement in terms regulation 41(7) of Dena Bank
(Employees’) Pension Regulations, 1995. However, if such a pensioner/employee applies
for commutation after one year from the date of his retirement the same will be subject to
medical examination. If the pensioner/employee is declared fit by medical officer
approved by the Bank or any medical officer of the rank of Civil Surgeon or Chief District
Medical Officer then he/she will be entitled to commute on the date of medical certificate
given by the concerned Medical Officer.
2 P.F No.
3 Designation
4. Last Branch/Department/Office where retired
5 Submitted Option Forms to Nearest Office
[**Write dates in the order day (DD), month (MM) and
year (YY)
6 Date of Birth
9 Present residential address Address 1
Address 2
City
Pin Code
…2

::2::
(WHEREVER FULL SALARY DRAWN BY THE RETIREE
YEAR &
MONTH
BASIC
PAY
(PAID)
ANY
( viz.
Officiating
Allowance,
etc)
TOTAL
1
2
3
4
5
6
7
8
9
10
TOTAL
TOTAL NO. OF DAYS ON LOSS OF PAY
DURING THE ENTIRE SERVICE OF THE
RETIRED EMPLOYEE
SUSPENDED & PUNISHMENT AWARDED
RETD. EMPLOYEE
Date :
Note :
Alternatively the blanks may filled in by hand in Block letters without the use of
carbon paper.
----------------------------------------------------------------------------------------------------------------------------
Certified that the details of Bank’s contribution and interest on Bank’s contribution and the salary
particulars declared by the above mentioned applicant who retired on or after 29/09/1995 and
prior to 27/04/2010 have been verified and found to be correct.
(The above particulars declared by the applicant are required to be checked by going
Signature :
Name in Full :
Designation :
Branch / Office :
PA No. :
( To be attested by the Branch Manager/Departmental Head (holding Power of Attorney
number with official seal after Verification of information furnished in the option form)

ANNEXURE- III( BLUE COLOUR)
( RETIREE TO SUBMIT FIVE COPIES)
[Option Form to be filled in by the employees who were in service of the bank prior to 29th
September, 1995 and retired under VRS 2000 after putting minimum period of 15 years of
service.]
Dena Bank,
Head Office,
MUMBAI- 400 051.
27.04.2010 for extending another option to join Pension Scheme. I have understood that the
terms of the Settlement / Joint Note have been arrived at on the basis of the Unions/
Associations offering to contribute 30 % of the initial funding gap assessed for extending another
option for joining the pension scheme. I am agreeable to the said contribution of 30 % towards
the funding gap and hereby voluntarily opt for Bank's Pension Scheme as per the provisions of
the said Settlement / Joint Note . I undertake to refund the Bank's contribution to Provident Fund
together with accrued interest thereon paid to me on plus an amount equal to 56 % of the Bank's
contribution to Provident Fund with interest received at the time of death/retirement being 30%
contribution towards the initial funding gap in terms of Joint Note dated 27.04.2010 and the
Settlement dated 27.04.2010.
I desire to commute 1/3 rd or ........................Part of the pension / I do not desire to commute any
part of the pension ( Strike out whichever is not applicable ). [ TO BE DECLARED ONLY BY
THOSE EMPLOYEES WHO WERE IN SERVICE OF THE BANK PRIOR TO 29th
SEPTEMBER, 1995 AND RETIRED UNDER VRS 2000 AFTER PUTTING MINIMUM PERIOD
OF 15 YEARS OF SERVICE. ]
Note : No medical examination shall be necessary if the application for commutation is
made within one year from the date of retirement in terms regulation 41(7) of Dena Bank
(Employees’) Pension Regulations, 1995. However, if such a pensioner/employee applies
for commutation after one year from the date of his retirement the same will be subject to
medical examination. If the pensioner/employee is declared fit by medical officer
approved by the Bank or any medical officer of the rank of Civil Surgeon or Chief District
Medical Officer then he/she will be entitled to commute on the date of medical certificate
given by the concerned Medical Officer.
2 P.F No.
3 Designation
4. Last Branch/Department/Office where retired
5 Submitted Option Forms to Nearest Office
[**Write dates in the order day (DD), month (MM) and
year (YY)
6 Date of Birth
Address 1
Address 2
City
Pin Code
….2

::2::
YEAR &
MONTH
BASIC PAY
(PAID)
SPL. PAY F.P.P. P.Q.P. OTHER IF ANY
( viz.
Officiating
Allowance, etc)
TOTAL
1
2
3
4
5
6
7
8
9
10
TOTAL
TOTAL NO. OF DAYS ON LOSS OF PAY
RETIRED EMPLOYEE
RETD. EMPLOYEE
Date :
Note :
2) Blanks in the form have to be preferably typed, ensuring that all copies are legible. Alternatively
the blanks may filled in by hand in Block letters without the use of carbon paper.
4) Pension Application & Commutation application will be required to be filled in subsequently by
all Pension Optees.
……………………………………………………………………………………………………………------
Certified that the details of Bank’s contribution and interest on Bank’s contribution and the salary particulars
declared by the applicant who retired under VRS 2000 under Special Scheme after putting minimum period
of 15 years of service have been verified and found to be correct.
(The above particulars declared by the applicant are required to be checked by going through the
employees personal file/service records available at the Branch level.)
Signature
Name in Full
Designation
Branch / Office
PA No. :

ANNEXURE- IV( PINK COLOUR)
( FAMILY MEMBERS OF RETIREE TO SUBMIT FIVE COPIES)
[Option Form to be filled in by the family of those who were in service of the bank prior to
29th September, 1995 but retired on attaining superannuation/retired under VRS 2000 and
subsequently expired, or expired while in service, before the date of Settlement / Joint
Note dated 27.04.2010.]
Dena Bank,
Head Office,
MUMBAI- 400 051.
Shri/Smt. ( Full Name)
was an employee of Dena Bank last working at Branch/Office. I , the
spouse/son/unmarried daughter/legally divorced daughter/guardian of the minor son/daughter of
the above named deceased employee, hereby declare that have read and understood the terms
of settlement/Joint Note dated 27.04.2010 for extending another option to join the Pension
Scheme. I have understood that the terms of the Settlement/Joint Note have been arrived at on
the basis of the Union/ Association offering to contribute 30% of the initial funding gap assessed
for extending another option for joining the pension scheme. I am agreeable to the said
contribution of 30% towards the funding gap and hereby voluntarily opt to become a member of
the Dena Bank Employees’ Pension Scheme as per the provisions of the said Settlement/Joint
Note . I undertake to refund the Bank’s contribution to Provident Fund together with interest
thereon paid to Shri/Smt on his/her retirement
/death while in service plus an amount equal to 56% of the Bank’s Contribution to Provident Fund
with interest received at the time of retirement being 30% contribution towards the initial funding
gap in terms of Joint Note dated 27.04.2010 of the settlement dated 27.04.2010 to the Dena Bank
Employees’ Pension Fund.
Note : Family so exercising the option would not be eligible to any benefit commutation
and shall be entitled to the benefit of Family Pension only.
1 Name of the deceased employee in Full :
Shri/Smt./Kumari (Delete whichever is not
applicable)
Late
2 Name of the
Widow/Widower,Guardian/Son/Unmarried
Daughter/Legally Divorced Daughter
3 Relationship with the deceased employee
4 P.F No.
5 Last Designation
6 Last Branch/Department/Office
7 Submitted Option Form to Nearest Office
[**Write dates in the order day (DD), month
(MM) and year (YY)
8 Date of Birth
11 Date of Death
Address 1
Address 2
City
Pin
retirement settlement. Please enclose photo
copies of the documents in support of the
above )
…2

::2::
YEAR &
MONTH
BASIC PAY
(PAID)
SPL. PAY F.P.P. P.Q.P. OTHER IF ANY
( viz.
Officiating
Allowance,
etc)
TOTAL
1
2
3
4
5
6
7
8
9
10
TOTAL
TOTAL NO. OF DAYS ON LOSS OF PAY DURING
THE ENTIRE SERVICE OF THE RETIRED
EMPLOYEE
DURING THE ENTIRE SERVICE OF THE RETD.
EMPLOYEE
Date :
Place : SIGNATURE/ OF THE APPLICANT
Note :
Alternatively the blanks may filled in by hand in Block letters without the use of
carbon paper.
3) Signature or Thumb Impression of Widow/Widower/Guardian/Son/Unmarried
daughter/legally divorced daughter should be duly attested by the Branch Manager
---------------------------------------------------------------------------------------------------------------------------
Certified that the details of Bank’s contribution and interest on Bank’s contribution and the salary
particulars declared by the applicant’s who was in service of the bank prior to 29th September,
1995 but retired subsequently and expired, or expired while in service, before the date of
Settlement / Joint Note dated 27.04.2010 have been verified and found to be correct.
(The above particulars declared by the applicant are required to be checked by going through the
employees personal file/service records available at the Branch level.)
Signature
Name in Full
Designation
Branch / Office
PA No.
............................................
Note : Additions/alterations in the text of the above form will render the option invalid.

ANNEXURE- V(GREEN COLOUR)
( FAMILY MEMBERS OF RETIREE TO SUBMIT FIVE COPIES)
[Option Form to be filled in by the family of those who were in service of the bank prior to
29th September, 1995 but retired subsequently and expired, or expired while in service,
after the date of Settlement / Joint Note dated 27.04.2010.]
Dena Bank,
Head Office,
MUMBAI- 400 051.
Shri/Smt. ( Full Name)
was an employee of Dena Bank last working at Branch/Office. I , the
spouse/son/unmarried daughter/legally divorced daughter/guardian of the minor son/daughter of
the above named deceased employee, hereby declare that have read and understood the terms
of settlement/Joint Note dated 27.04.2010 for extending another option to join the Pension
Scheme. I have understood that the terms of the Settlement/Joint Note have been arrived at on
the basis of the Union/ Association offering to contribute 30% of the initial funding gap assessed
for extending another option for joining the pension scheme. I am agreeable to the said
contribution of 30% towards the funding gap and hereby voluntarily opt to become a member of
the Dena Bank Employees’ Pension Scheme as per the provisions of the said Settlement/Joint
Note and cease to be a member of Contributory Provident Fund Scheme. I undertake to refund
the Bank’s contribution to Provident Fund together with interest thereon paid to Shri/Smt
on his/her retirement / death while in service plus an
amount equal to 2.8 times of revised pay for the month of November,2007 representing 30%
contribution mentioned above from the arrears paid on account of Wage Revision in terms of
Bipartite Settlement/Joint Note dated 27.04.2010 to the Dena Bank Employees’ Pension Fund.
Note : Family so exercising the option would not be eligible to any benefit of
commutation and shall be entitled to the benefit of Family Pension only.
1 Name of the deceased employee in Full :
Shri/Smt./Kumari (Delete whichever is not
applicable)
Late
2 Name of the
Widow/Widower,Guardian/Son/Unmarried
Daughter/Legally Divorced Daughter
3 Relationship with the deceased employee
4 P.F No.
5 Last Designation
6 Last Branch/Department/Office
7 Submitted Option Form to Nearest Office
[**Write dates in the order day (DD), month (MM)
and year (YY)
8 Date of Birth
11 Date of Death
Address 1
Address 2
City
Pin
retirement settlement. Please enclose photo
copies of the documents in support of the
above )
…2

::2::
STATEMENT OF SALARY DRAWN BY THE RETIREE FOR THE LAST 10 MONTHS PERIOD
PRIOR TO THE DATE OF RETIREMENT
YEAR &
MONTH
BASIC
PAY
(PAID)
ANY
( viz.
Officiating
Allowance,
etc)
TOTAL
1
2
3
4
5
6
7
8
9
10
TOTAL
F.P.P. & P.Q.P. - FURNISH INCREMENT COMPONMENT ONLY (i.e. Without D.A.)
TOTAL NO. OF DAYS ON LOSS OF PAY DURING THE ENTIRE SERVICE OF THE
RETIRED EMPLOYEE
SUSPENDED & PUNISHMENT AWARDED DURING THE ENTIRE SERVICE OF
THE RETD. EMPLOYEE
Date :
Note :
Alternatively the blanks may filled in by hand in Block letters without the use of carbon
paper.
----------------------------------------------------------------------------------------------------------------------------
Certified that we have recovered 2.8 times of basic pay components of revised pay for
November,2007 Rs.
(Rupees ..........................................................................................................
only) from Mr./ Ms.........................................................................(PF No..................................) and
date of credit to Suspense Receipt Account - Contribution towards Pension Gap
(The above particulars declared by the applicant are required to be checked by going
Signature
Name in Full
Designation
Branch / Office
PA No.
( To be attested by the Branch Manager/Departmental Head (holding Power of Attorney number with
official seal after Verification of information furnished in the option form)

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