Annexure B

APPLICATION FORM FOR REVISION OF PPO

1. Name of the applicant (In block letters) : GURDIAL SINGH

2. Full Postal Address: House No. 292, Ward No. 9, Nanak Nagari , Moga, Punjab-142001

3. Name of the Railway Pensioner & Designation : GURDIAL SINGH , JUNIOR
ENGINEER (J.E)-1, RDSO, Ministry of Railways, Lucknow-226011.

4. Date of Retirement of Railway Servant: 01-08-2005

5. a) Name of the spouse & DOB (with proof): GIAN KAUR , 15-08-1954
b) Name of dependent & DOB (with proof):
c) Relation with deceased pensioner:
(I) Un married Daughter:
(ii) Widow/Divorce daughter: -
(iii) Handicapped son/daughter:
(iv) Wholly dependent parents:
(y) Disabled Siblings:
(vi) Any Other:

6. Date from which Pension/Family Pension is drawn: 01-08-2005

7. PPO No. : 0105150097

8. Pay Scale & Last Pay: Pay scale : Pay Scale: 5500-9000, Last Pay : 8825

9. Name of the authority which Issued PPO (copy enclosed): Executive Director Finance,
Finance & Accounts Directorate, R.D.S.O Lucknow-226011

10. Name of the Bank & address A/c No.:
A/c No : 30006725166 ,
STATE BANK OF INDIA, G.T. ROAD, MOGA, PUNJAB-142001
BSR Code : 0001775 , IFSC Code : SBIN0001775

11. Documents required:
a) Copy of PPO at the time of retirement
b) Revised PPO as on 01.01.1996
c) Proof of date of birth of spouse


Signature
(Pensioners/Family Pensioner / Dependent)
Place :
Date :