19

Encls 1 to Appx ‘A’ to Chap III of GMO 2023

AFMSF-16 (Ver 2023)

MEDICAL BOARD PROCEEDINGS Passport size

Photograph
INVALIDMENT / RELEASE IN LOW MEDICAL CATEGORY/ duly attested
APPEAL MEDICAL BOARD (First/Second)/PDC by CO

PART – I

[Link] for Board [Link]/Hospital [Link] -

Release order : -
_ _/_ _/_ _ _ _

[Link] 5. Sex : M/F 6. Service [Link] 8. Date of Birth 9. Contact number

2
No. & Email ID
_ _/_ _/_ _ _ _

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[Link] / Ship
09 2
11 .Service(Army / [Link] / Corps / [Link] [Link] Flying

3
Navy / Air Force) Branch / Trade Service Hours / Service
6.
Afloat
0 .
4
23

[Link] 16. Name 17. Date of 18. Date of 19. (a) Record Office -
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Address: & relation commissioning/ Retirement/

of NOK Enrolment: Release
2
02 4.

_ _/_ _/_ _ _ _ _ _/_ _/_ _ _ _

1/
13

[Link] Marks: (a) 21 (a) Height (cm) -

(From service I-Card) (b)
(b) Weight (Kg) -

Signature of Witness ………………………. Signature of Individual…………………………

Service No……………..Rank………………… Service No…………..Rank…………………
Date…………………………. Date…………………………..

Member Member President

Indl Sig ……………………. 20
Service No………..Rank…………….
Name
PART ……………………………………

II
PERSONAL STATEMENT

1. Give details of service. (P= Peace OR F= Field / Operational / Sea service) *

*(Copy of paramount card and Part –II orders for service in Fd/Mod Fd/CI Ops/HAA/sea service/operational
area/Others for the indl undergoing RMB/IMB to be att).

S Place/ P/F(HAA/Ops/Sea S Place/ P/F(HAA/Ops/Sea

From To Unit From To Unit
No Ship service)/Mod Fd No Ship service)/Mod Fd
(a) (b)

(c) (d)

2
(e) (f)

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(g) (h)

09 2
3
6.
2. (a.) Did you suffer from any impairment before joining the Armed Forces? If so give details and dates.
0 .

(b.) Were you previously employed in service? If so, are you in receipt of any impairment relief? Give details.
4
23

(c.) Did you take any treatment from any civil or private sources? If so, give details and reasons for taking
/1 6

treatment from civil resources.

2
02 4.
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(d.) Did you refuse any treatment or surgery? If so, give details and reasons for refusal.

(e.) Did you sustain any injury resulting in impairment? Give ref of injury report and COI. Give reasons for non
13

submission of injury report at the time of injury, if injury report not submitted.

(f.) Did you delay any of your AME/PME or did not carry out AME/PME for any year/age? Is so, give details.

(g.) Did you report for review of your medical cat as per advice of Medical Board? Give details of delayed
medical board if any and reasons for the delay.

Signature of Witness ………………………. Signature of Individual…………………………

Service No……………..Rank………………… Service No…………..Rank…………………
Date………………………….. Date……………………

Member Member President

21 Indl Sig …………………….
Service No…………Rank……….
Name…………………………………

3. Give particulars of any diseases or injuries from which you are suffering

Illness/ injury First Started Rank of Individual Where Approximate dates and
treated periods treated (Attach
Date Place documentary evidence)

4. Give details of any incidents during your service, which you think caused or made your impairment
worse.

5. Any other information you wish to give about your health

2
I certify that I have answered as fully as possible all the questions about my service, personal history

:0 1
and that the information given is to the best of my knowledge.

09 2
3
6.
Signature of Witness ………………………. Signature of Individual……………………
Service No……………..Rank………………… Service No…………..Rank…………………
0 .

Date…………………………. Date…………………………..
4
23
/1 6
2

NOTE: The questions should be answered in the individual’s own words. This statement and the
02 4.
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data given above will checked from official records as far as possible by the parent Unit/Ship of the
individual. Particulars including identification marks and height from Service identity card and weight
measured shall be authenticated by the Commanding Officer (auth to sign not to be delegated).
13

( )
Signature of CO
Unit Stamp No…………….
Rank………….
Name……………………………
Date …../……./………

Member Member President

22
Indl Sig …………………….
Service No…………Rank………….
Name……………………………………

PART III
STATEMENT OF COMMANDING OFFICER/COMDT/FMN CDR

1. Date the individual joined your Unit / Ship -

2. Was the individual in Low Medical Category (Y/N) ______________, If Yes

(a) What was / were the impairment(s)?

(b) What was the medical category and since when? (Mention date of last Categorization Medical
Board)
(c) How long has the individual been in low medical category?

3. Was the individual excused any duty?

2
(a) Type of duties excused :

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(b) Was the individual excused BPET/PPT?

4. Nature of duties in the Unit (Give details)

09 2
3
6.
5. Did the duties involve Severe / exceptional stress and strain? (Give details).
(a) Since when
(b) On special day/occasions
0 .

6. Was the individual living with his family? If so-

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23

(a) Since when

(b) In Govt accommodation or under own arrangements
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7. Was the individual living in Unit lines?

2
02 4.
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8. Dates of leave over last two years with full leave address.
13

9. If impairment is due to an infection

(a) Any other case in the unit.
(b) Is the disease endemic in the town in surrounding areas?
(c) Preventive measures taken?
10. In case of Sexually Transmitted Diseases/Immune surveillance
(a) When and where was it contacted?
(b) Name of Hospital / STD centre where treated.
(c) Was surveillance and follow-up treatment completed?
(d) If surveillance and follow-up treatment was not completed, state service factors responsible.

[Link] to be attached by Commanding Officer (Provide ref letter numbers) (Tick the docuatt)
(a) Injury Report (for injury cases)
(b) COI (if applicable)
(c) Copy of initial and latest AFMSF 15
(d) Copy of latest AME/PME
(e) Copy of release order
(f) Certificate by CO prior to onset (in CAD cases)
(g) Any other relevant document

Unit / Ship Station Signature of Commanding officer/Comdt/Fmn Cdr

Date Rank & Name in full

Member Member President

23
Indl Sig …………………….
Service No……………Rank…
Name ……………………………
PART – IV

ENDORSEMENT BY COMMANDING OFFICER/COMDT/FMN CDR

(1) Details of the indl.

S No. Nomenclature Remarks

(a) Present Med Cat
(b) Date of receipt of retirement/release
order
(c) Date of release/retirement
(d) Date of referral to AMA
(e) Present loc of unit (P/F/HAA/CI
Ops/MF)
(f) Deployment of indl to places/units to
other units during posting to your unit

2
(2) Courses attended.

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S No. Course From To Place of course P/F/MF/HAA/CI Ops
09 2
3
0 . 6.
(3) Temp duties in Op areas/Fd areas/HAA/CI Ops.
4
23

S Temp Duty From To Unit and Place of P/F/MF/HAA/CI Ops

/1 6

No. deployment
2
02 4.
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13

Signature of indl Signature of CO

Service No…………… Service No……………
Rank …………………. Rank ………………….
Name…………………. Name………………….
Date : _ _/_ _/_ _ _ _ Date : _ _/_ _/_ _ _ _

Member Member President

24
Indl Sig …………………….
Service No……………Rank…………
Name…………………………………

PART – V
MEDICAL EXAMINATION

1. (a) Total Nos of Teeth (b) Missing /Unsaveable teeth

(b) Total No Defective Teeth U.R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U.L
(c) Dental Points L.R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L.L
(d) Condition of gums Missing teeth to be indicated by Horizontal line(__) and
unsaveable teeth by a cross (x) through the appropriate
number
2. Investigations
3. (a) Physical capacity
(i) Height ……cms (ii) Weight actual….. Kg (iii) Ideal Wt…..Kg (iv) Over weight ……%
(v) Waist …….cms (vi) Chest full expansion……..cm (vii) Range of Expansion………..cms
(b) Skin
(c) Cardio Vascular System

2
(i) Pulse……../min (ii) BP …………mm/Hg (iii) Peripheral pulsations
(iv) Heart size (v) Sounds (vi) Rhythm

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(d) Respiratory System
(e) Gastrointestinal System
(i) Liver Palpable (Y/N) ……….cm
09 2 (ii) Spleen Palpable (Y/N)…………… cm

3
(iii) Hernia/ Hydrocele (Y/N)……………(iv) Haemorrhoids (Y/N)……………
6.
(f) Central Nervous System
(i) Higher Mental Functions (ii) Speech (iii) Reflexes
(iv)Tremors: Nil/Fine/Coarse. (v) Self Balancing Test : Fairly steady/Unsteady.
0 .

4. (a) Locomotor System NAD (b) Spine NAD

4
23

5. (a) Distant Vision R L (b) Near Vision R L (c) CP

Without Without
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Glasses Glasses
2

With glasses With glasses

02 4.
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6 (a) Hearing R L Both (e) Audiometry record

FW cms cms cms
13

CV cms cms cms

(b) Tympanic membrane Intact Y/N Y/N

(c) Mobility (Valsalva)
(d) Nose, Throat, &Sinuses NAD/
7. Gynaecological Examination
(a) Menstrual History (b) LMP
(c) No of Pregnancies (d) No of abortions
(e) No of Children (f) Date of last confinement
(g) Vaginal discharge (h) Prolapse
(j) USG Abdomen (k) Breast
Remarks

Date Signature of MO

1. Delete what is not applicable. In case any abnormality is detected, delete “NAD” and enter
findings.

2. This part is to be completed by AMA in case of Release in low medical category, and by ward MO
in case of Invalidments.

Member Member President

25

PART VI
Indl Sig …………………….
Service No……………Rank……
STATEMENT OF CASE
Name…………………………
1. Chronological list of the diseases/impairment

Diseases/Impairments Date of Rank of Place and

origin the Indl unit where Date of initial AFMSF 15 for each
serving at the disease/impairment
time

2. Clinical details.

(a) Detailed history:

(b) Personal History:

2
(To include history of smoking/tobacco chewing, alcohol intake, etc)
(c) Family history:

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(To incl history of life style disorders, psy illnesses, hereditary disorders, etc)
(d) Treatment History:
(e) Specialist report (Including History of presenting illness, Clinical Examination,
09 2
Relevant Investigations, Details of treatment, present condition, Summary and Final Opinion

3
for all diseases and impairments)
6.
(f) Certified that all AFMSF-15 and other hospitalization documents are available incl
latest AFMSF – 15. If not so, Give details.
(g) Copy of retention certificate (if applicable).
0 .

(h) Approved copy of Retention and impairment assessment board.

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23

(j) Certificate for accepting/rejecting capitalizing impairment.

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2

Signature of President Medical board

02 4.
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Note. Insert the clinical summary sheet between page 7(A) &8, without any folds.
13

PART VII

OPINION OF THE MEDICAL BOARD

1. Please endorse diseases/ impairments in chronological order of occurrence

Impairment Attributable Aggravated DETAILED JUSTIFICATION

to service by service
(Y / N) (Y / N)
(a)

(b)

(c)

(d)

Note: 1. A detailed justification regarding the board’s recommendations on the entitlement for each
disease/ impairment must be provided sequentially in all cases as per enclosed Appendix ‘A’.
2. In case of multiple impairments or inadequate space, do not paste over the opinion, an additional
sheet should be attached instead, providing a detailed justification, which is authenticated by the
President and all members of the Medical Board.
3. In case the Medical Board differs in opinion from the previous Medical Board, a detailed
justification explaining the reasons to differ should be brought out clearly.
4. An impairment cannot simultaneously be both attributable to or aggravated by military service,
only one or neither of which will apply.

Member Member President

26

Appendix ‘A’

Indl Sig …………………….

Service No……………Rank……………
Name …………………………………

(As per Note 1 of Part VII of AFMSF – 16)

DETAILED JUSTIFICATION FOR ALL CASES

1. Why is the disease related/not related to service as per job profile and place of posting.

2. If the disease is constitutional / hereditary / due to the process of ageing etc, why was it not
detected at the time of recruitment / commission.

3. The detailed list of documents that have been verified to come to the conclusion that the
disease is NANA :-

2
(a) Initial Medical Board (AFMSF – 15) including specialist opinion
(b) Release Medical Board (AFMSF – 16) including specialist opinion

:0 1
(c) Posting Profile
(d) Job Profile
(e) Medical Case Sheets
09 2
3
(f) Latest AME / PME
6.
(g) Injury Report / C of I proceedings
(h) Certificate by CO prior to onset of disease in certain cardiac conditions
(j) Any others
0 .
4
23

Note :- Board will summarise their findings based upon the above, they will comment upon any
hastening in onset or worsening of the disease due to service conditions and not merely mention as
/1 6

per the specialist opinion enclosed.

2
02 4.
1/
13

Member Member President

27
Indl Sig …………………….
Service No……………Rank………
Name………………………………
…

1. (a) Was the disease/impairment attributable to the individual's own negligence or misconduct ? If
Yes, in what way?
(b) If not attributable, was it aggravated by negligence or misconduct? If so, in what way and to what
percentage of the total disablement?
(c) Has the individual refused to undergo operation / treatment? If so, have the individual's reasons
will be recorded. Note :-In case of refusal of operation/treatment a certificate from the individual will be
attached.

(d) Has the effect of refusal been explained to and fully understood by the individual, viz, a reduction
in, or the entire withholding of any impairment relief to which he/she might otherwise be entitled?

(e) Does the Medical Board consider it probable that the operation / treatment would have cured the
disease/ impairment or reduced its percentage?
(f) If the reply to (e) is in affirmative, what is the probable percentage to which the disease /

2
disablement could be reduced by operation/treatment?

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(g) Does the Medical Board consider individual's refusal to submit to operation / treatment
reasonable? Give reasons in support of the opinion specifying the operation/treatment recommended.

09 2
3
(h) Does the individual claim to be suffering from any other disease / injury apart from those listed in
6.
Para 3 of Part – II.

2. What is present degree of disease /disablement as compared with a healthy person of the same
0 .

age and sex? (Percentage will be expressed as Nil or as follows): 5%, 10%, 15% upto 100%. If the
4

assessment given in Ch VII as per RPwD act assessment guideline then exact % will be mentioned.
23

Assessment sheet will be signed by concerned specialist and all members of the medical board to
/1 6

verify its correctness. No rounding off will be done by the board.

Disease /impairment (As Percentage Corresponding Composite Impairment Net
2
02 4.

numbered in Para 1 of para of GMO assessment Percentage Assessment

1/

Part VI) impairment for all Qualifying Qualifying for

impairments for Disability
13

(Max 100%) Disability Pension/

with Pension/ Impairment
duration Impairment Relief(Max
Relief with 100%) with
duration. duration
(a)

(b)

(c)

(d)

Note: Assessment of impairments not mentioned in the Guide to Medical Officers(Mil Pens) is to be
done on the basis of best available medical evidence

4. Is the individual in need of further treatment and, if so, of what nature and for how long is it likely to
be required?

5. Does the individual require constant attendant? If so how long?

Member Member President

28
Indl Sig …………………….
Service No………………Rank…….
Name………………………

Invalidment / Release in Medical Category ……………………………………………………………….

Place

Date Member Member Signature of President

APPROVING AUTHORITY
(Not applicable for Navy)

:0 1
2
Place
09 2 Signature

3
6.
Date Designation
0 .

CONFIRMING AUTHORITY
4
23

(Not applicable for Navy)

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2
02 4.
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Place Signature
13

Date Designation

ACCEPTING AUTHORITY
(Not applicable for Navy)

Place Signature

Date Designation
29 Indl Sig …………………….
Service No…………………Rank…….
Name …………………………………

CERTIFICATE FOR COMMUTATION OF PENSION

The Medical Board having carefully examined No………………………. Rank ……………… Name
……………………………………………….….Unit………………………are of the opinion that :

The individual is suffering from ………………………………………………………………..………… but is

otherwise in good bodily health and has the prospect of an average duration of life. Commutation of
pension in his / her case is therefore, recommended for acceptance.

OR

The individual is suffering from ……………………………………………………………………….… and

as the consequence there of he / she is not in good bodily health and does not have the prospect of
an average duration of life. The Medical Board therefore, does not recommend acceptance of
commutation of pension in his / her case.

2
OR

:0 1
The individual is suffering from …………………………………………………………………………. The
Medical Board is of the opinion that he is not in good bodily health and does not have the prospect of

09 2
an average duration of life. The Medical Board however, recommends compliance with his application

3
to be allowed to capitalise a portion of his pension by Rank, on his / her age for the purpose of
6.
commutation i.e. his age next birth day should be ………………………year (s) more than his actual
age.
0 .
4
23
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2

Signature of Individual Signature of President

02 4.
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Date Date
Notes.
1. Addition to actual age should be indicated in full years.
13

2. While furnishing the above certificate, Medical Board should bear in mind that the recommendation
for commutation, or otherwise in pension is not related to the diagnosis as such but the likely effect
which the impairment has on the individual's longevity of life. Impairments, which do not affect
longevity, should invariantly be recommended for full commutation of pension as admissible.

3. However where the impairment is likely to effect the longevity of an individual the Medical Board
should consider whether commutation should not be recommended at all or recommended with
loading of age. In other words, if the impairment is so severe that longevity of the individual has been
seriously curtailed, they should not recommend commutation of pension at all. If on the other hand,
they feel that the longevity of the individual has diminished but, not severely they may determine in
imaginary age of the individual which, accept to his existing condition would correspond to the residual
longevity and recommend that the age of the individual be reckoned as such. For example in IHD
case, if the individual's disease is fully compensated and is without any complications, he may be
considered to have normal chances of longevity. However, in case of severe infarction not fully
compensated where chances of longevity are not considered to be equal to those of a normal person
the board should recommend addition of appropriate number of year / years to the actual age for
commutation purposes. This is known as "Loading of age".

Member Member President

30
Indl Sig …………………….
Service
11 No……………Rank…………….
Name …………………………………

EMPLOYABILITY OF ARMED FORCES PERSON RETIRING IN LOW MEDICAL CATEGORY

The inherent stress and strain in the military service has been recognized the world over as
Armed Forces personnel stay away from their family during a major portion of service in a regimented
lifestyle under a strict disciplinary code in harsh and hostile environmental conditions. Consequently,
for personnel serving in such conditions, even common ailments such as hypertension, Diabetes,
CAD, minor psychiatric illnesses or psychosomatic disorders are bound to get aggravated by all
domestic events such as property disputes, family problems, education of children, etc.
Additionally, the progressive provisions of Section 20 of ‘The Rights of Persons with
Disabilities Act, 2016’ have not been made applicable to the Armed Forces as they are meant to retain
a fighting fit profile. Whereas, under the same Act, a civilian Government employee if disabled under
any circumstances will be paid full pay and allowances till the age of 60 years and full pension
thereafter. Thus, many a times, personnel cannot be retained in service inspite of their being fitter than
their civilian counterparts.
Low Medical Category (LMC) in the Armed Forces is for conditions specific to service and is

2
meant for employability restrictions for varied climatic conditions / terrain deployment/active war
service/Operational requirements etc. Post retirement, once the stressors of Armed Forces have

:0 1
ceased to exist, the individual would be able to perform routine/regular duties in a normal manner just
like any other civilian. However the fitness of the individual to perform duties in any job/employment
09 2
should be commensurate with the composite assessment of disablement as assessed by the Medical

3
Board. Similarly in case of aircrew invalided / released in medical category A4(P) i.e. permanently unfit
6.
for A1, A2 and A3 duties, the certificate should also state that he is unfit for civil aircrew duties but fit
for other duties.
0 .

Therefore, this fitness certificate of employability as on date of signing is being issued with the
4
23

specific intent and purpose to convey to all prospective employers regarding the ability of the
concerned ex-serviceman, whose particulars and details have been provided below.
/1 6
2

FITNESS CERTIFICATE FOR CIVIL EMPLOYMENT

02 4.
1/

To whomsoever it may concern:

13

1. This is to certify that No. -------------------------------, Rank ---------------------------------, Name -------

-------------------------------------------------------------------------------------------, is being discharged from service
after completion of full term of service/PMR in Low Medical Category for the following conditions:
(a)
(b)
(c)
(d)

2. He / She is:
(a) FIT FOR ALL TYPES OF EMPLOYMENT IN CIVIL.
(b) FIT FOR ONLY SEDENTARY EMPLOYMENT IN CIVIL.
(c) FIT FOR ALL EMPLOYMENT NOT INVOLVING HEAVY MACHINERY / MOVING
PARTS.
(d) UNFIT FOR EMPLOYMENT IN CIVIL REQUIRING HIGH PHYSICAL / MENTAL
FITNESS.
(e) FIT FOR ALL TYPES OF CIVIL AIRCREW DUTIES.
(f) ANY OTHER (SPECIFY).
(g) UNFIT FOR ALL TYPE OF EMPLOYMENT IN CIVIL.

(AUTH: RMB/IMB dated ……………………………, held at ……………………………… )

Note:-This certificate will be an integral part of Service Book of all Ex-servicemen undergoing
RMB/IMB. The Service Book copy will be signed by concerned Record Officer quoting authority of
IMB/RMB with date.

Member Member President

Indl Sig …………………….
31 Service No…………Rank……….
Name ……………………………
PART VIII

ROLL OF JCO/OR PROPOSED TO BE INVALIDED

No. Information Required Answers

1 Army / Navy / Air Force Service Official No.
Rank Airman, Group and Name (Name should be hand
2.
Printed).
3. Regt. Corps / Ship / Establishment

4. Date of birth

5 Age on enrolment Years Days

6. Date of enrolment
Date of advancement to Rank
Date of advancement to airman's service

:0 1
2
7. Height

8.
identification marks). 09 2
Personal appearance (colour of hair and eyes and

3
6.
Village / Pargana /
Permanent home address on being discharged (to be
Tehsil
9. hand
Post Office
0 .

printed).
District
4
23

10. (a) Substantive rank (s) held during the last 2 years with
dates of promotion / advancement.
/1 6
2

(b) Acting rank held, if any

02 4.
1/

Periods with dates of service in each pay group (if more

11. than one group has been held during the last 2 years of
13

service).

Rate of pay last admitted (in case of non-combatants

12. claiming impairment person under military rules) and Rule
or Order under which admissible.

Date of discharge (the date upto which effective pay has

13.
been admitted).

14. Service to date of discharge

Service to date on which Medical Board Proceedings are

15.
countersigned by ADGMS Army / DGMS Navy/ DGMS Air.
Periods not counting as qualifying service for pension (See
Rules 195, 196 and 211 of Pension Regulations for the
Army, Rules 164 & 181 of Pension Regulations for the
16. Navy and Rules 3 and 8 of para 207-A of pay and
Allowances Regulations for Air Force 1942).
32
Indl Sig …………………….
Service No…………Rank…………….
Name …………………………………

No. Information Required Answers

17. Any previous Army, IN or IAF service counting towards
pension or gratuity as verified by the Defence Accounts
Department (quote authority).

18. Character

19. Whether recommended for the grant of personal

allowance of Rs. 50 (in the case of Risaldar Major /
Subedar Major who elects to be governed by the old
pension code).

20. Pension Paying Agency / Treasury / Sub-Treasury from

which desirous of drawing pension. Note :-The place
should be one of those mentioned in Financial

2
Regulations of India, Part I Appendix IV (or in
Annexures, I & I I& A.F.I. 166/43, in the case of I.A.F.

:0 1
Personnel.
21. Invalid / impairment relief for which recommended.
09 2
3
Note. Orders of the competent authority are necessary for deduction in the amount of invalid gratuity /
6.
pension and for the grant of gratuity / in the case of those invalided on account of disorders (including
insanity) brought on by indulgence in drugs or drink. (Rules 200, 232, 233, 252, 253 and 336 Pension
Regulations Part II read with A.I. 5/S/56 as amended by A.I. 12/57: Rules 167, 189, 190 and 193 of
0 .

Pension Regulations for Navy and N.I. No. 1/S/57 and para 12 of A.F.I. 92/42, sub-paras 12& 13 para
4
23

207-A of P&A. Regulations for Air Force 1942 and A.F.I. 5/S/56).
22. Allowances to which entitled when pensioned: - Amount Authority for
/1 6

Rs P same
2

(a) Personal Allowances as Risaldar Major or Subedar

02 4.
1/

Major per mensem (only if a JCO elects to be governed

by the old Pension Rules).
13

(b) Allowances in respect of Gallantry Awards or other

decorations :-
(i)-------------------------
(ii)------------------------
(iii)-----------------------
(iv)-----------------------

23. Whether he was granted any pension (Civil or Military)

previously. If so, quote No. and date of Pension Circular /
Pension Payment Order and the amount of Pension.

24. Whether any impairment relief claim has or had been

submitted in respect of previous service. If so, with what
result (Quote authority for accepting/rejecting the claim).

25. Name and relationship of next of kin or other person to

whom arrears of pension are to be paid on demise of the
pensioner.

Signature or thumb and finger impressions (in case of illiterate persons only) of the left hand ofIndl

……………..………………………………………………….. (to be attested by a Commissioned Officer)

33

Indl Sig …………………….

Service No…………Rank………
Name………………………………

In cases of impairments due to accidents, the officer-in Charge, Records or the Officer Commanding,
Unit should certify here

(a) Whether the impairment was sustained according to the information available, while the
individual affected was in actual performance of Military / Naval / Air Force duty and if so, what was
the nature of such duty and.

(b) Whether in his opinion, the impairment was attributable to Field / Military / Naval / Air Force
Service and he should state the reasons underlying his opinion as regards attributability.

Certified that ……………………………………………………………………………………... will be

2
discharged with effect from …………………………………………... (Dates shown at item 13 on page

:0 1
12 to be entered).

09 2
I consider the man's refusal to undergo operation / treatment to be reasonable / unreasonable for the
following reasons: -

3
0 . 6.
4
23

Station:
Dated: Officer Commanding / Officer-in-Charge, Record Office
/1 6
2
02 4.
1/

I certify that the particulars given are correct as far as can be ascertained from the records of the
Regiment Corps / Ship / Establishment / Air Force and recommend that full / 3/4th pension admissible
under rules may be sanctioned.
13

Station………………………..
Dated………………………… : Officer Commanding / Officer-in-Charge, Record Office

Note :-1 Audit Officers will bring to the notice of the competent authority any abnormal delay between
the date on which the Board Proceeding are countersigned by the ADMS Army /DGMS Navy /Air and
the date on which the man is discharged by the Officer-in-Charge, Record Office. In case where a
Gorkha Rank whose home is in Nepal, is found unfit for further service by a Medical Board and the
Proceedings are signed by the ADMS after 15th June, the Officer-in-Charge, Record Office, will record
in the above certificate that the man will be retained with him until 15th September and discharged
with effect from that day.

2. The Officer-in-Charge Record Office will specify the date of discharge before the claim to pension is
submitted to the Audit Office concerned.

3. In the case of Air Force Personnel, the functions of Record Office will be performed by the
Directorate of Personnel (Airmen) Air Headquarters.
34
Indl Sig …………………….
Service No……………Rank………….
Name……………………………………
…

RECOMMENDED

Station……………….. . Commandant / Commanding Officer

Dated ………………… Brigade / Sub-Area
Commodore Naval Barrack

SANCTIONED

Station ………………..
Dated …………………Commandant / Commanding Officer
(See Army Rule 13, Table Item I (ii), II (ii), III (iii) & IV )

2
FOR USE IN THE DEFENCE ACCOUNTS DEPARTMENT

:0 1
Invalid
Pension/compensation admitted
09 2
3
Impairment
Rs. ………………………… (Rupees ……………………………………………………………only) p.m.
6.
vide P.P.O. No ………………………………………………………………………. dated ……..………..
Serial No :………………..
0 .

A.A.O. (P) …………………A.C.D.A. (P)..……………. D.C.D.A. (P)……………..

4
23

INSTRUCTIONS :
/1 6

1. Part VIII will be completed only when it is proposed to invalid a JCO / OR / Sailor / Airman
2
02 4.

(including M.W.O.).
1/

2. Part VIII will be completed by the Officer-in-Charge, Record Office, after receipt of Medical
Board Proceedings but before the submission of the pension claim to the CDA (P).
13

3. Two copies of this form (duly completed), will be submitted by the Officer-in-Charge, Regt /
Corps Record Office to the Staff Officer of the station of assembly of Medical Board of transmission
through the Independent Brigade or Area Commander to the Medical Board. In the case of I.N.
Sailors, three copies of this form (duly completed) will be submitted by the Commanding Officer Ship /
Estd. to Hosp. / Sick Bay where the Medical Board is to be held. In case of M.W.O. / W.O / Airman,
two copies of this form (duly completed), will be submitted by the Commanding Officer of the Unit
concerned to Medical Board.

4. Claims to Disability Pension/Impairment Relief should invariably be accompanied by (a)

AFMSF-81 (old IAFM-1231) in case of disablement on account of disease, and (b) IAFY-2006 and
proceedings of Court of inquiry (where required under RA Instruction 346), IAFF (P) 23 and
Proceedings of Court of Inquiry where required, in case disablement on account of wound or injury.

5. Claims for Disability Pension/ Impairment Relief, supported in each case by the sheet Roll, will
be submitted to the CDA (P) direct, except in the following cases where they will be submitted through
the Independent Brigade or Area Commander /Air Headquarters.

(a) Risaldar Majors / Subedar Majors who elect to be governed by the old pension code
and who are recommended for the grant of personal allowance of Rs. 50 p.m.

(b) All JCOs / OR / Airmen (including [Link] / NCs (E) who are invalided on account of
disorders (including insanity) brought on by indulgence in drugs or drink.