ANNEXURE XII

PROCEEDINGS OF THE DISTRICT EDUCATIONAL OFFICER / SANCTIONING AUTHORITY

FAMILY BENEFIT SCHEME – SANCTION FORM

Data Entry & Printable Sanction Order / Statement

1. Sanction Order

Sanctioning Authority / Office

Present / Officer Name

Order No.

Order Date

Subscriber Name

Designation

Office Address

Nature of Case

Date of Death / Retirement / Resignation / Relief

Net Amount Sanctioned (₹)

Amount in Words

Additional Order Text / Remarks

2. References

References

Head of Account

3. Statement

1. Subscriber’s name with designation and official address in full

2. Date of Birth

3. Date of Entry into Regular Service

4. Date of Filing Option

Date of Acceptance

5. Date from which subscriber opted the Scheme (effective date)

6. Class IV Employee?

7. Rate of Subscription (₹)

8. Date of Death / Retirement / Resignation / Relief

9. Years of service after joining scheme

10. Total amount at subscriber’s credit (₹)

11. Government contribution (₹)

12. Total amount due (₹)

13. Arrear subscription adjusted/recovered (₹)

14. Specific reason for arrears / whether willful default

15. Net amount payable (₹)

16. Whether deceased subscriber is survived by family (wife/husband/children)

17. Valid nomination?

Scheme of nomination

4. Nominee Details

Sl. No.	Name	Age	Relationship	Address	Share payable to each	Action

19. Mode of settlement of claim in respect of minors

20. Cheque / Department procedure under GO(P) No. 591/78/Fin. dated 28-07-1978

21. If only part of amount is sanctioned, reason / previous sanction and payment details

22. Other details, if any

5. Sanctioning Authority

Name

Designation

Place

Date

Signature / Office Seal

Notes: Item 10 applies only in the case of retirement / relief / resignation. Item 15 is the same as in the sanctioning order. Items 15 to 19 apply only in the death case while in service.