TNAG-2667-FCO40-3864-Hong-Kong-Civil-Service-1993 — Page 103

Section A

(for completion by officer)

Revocation of Nomination of Spouse for Death Gratuity and Ex-gratia Payment

Distribution:

Annex C

Original Treasury Duplicate--Head of Department Triplicate Officer

To: Secretary for the Civil Service via

(Head of Department)

I,

for

on

holder of HK Identity Card No.

(name of officer) hereby REVOKE the nomination made

(full name in BLOCK letters)

of (address)

to receive the death gratuity or ex-gratia payment which may be payable under the Pensions Ordinance (Cap. 89), Pension Benefits Ordinance (Cap. 99) or the Pension Benefits (Judicial Officers) Ordinance (Cap. 401) and request you to cancel the above-mentioned nomination.

Name:

(BLOCK Letters)

Rank:

TRN:

Address:

Witnessed by:

Signature:

HK Identity Card No.:

Date:

Name:

Signature:

(BLOCK Letters)

HK. Identity Card No.:

Date:

Section B

(for completion by department)

To: Secretary for the Civil Service via

Director of Accounting Services,

Revocation of nomination is forwarded. A copy of this form has been returned to the officer for his retention.

Rank:

Date:

Note

Signature:

(for

>

(Head of Department)

Name:

In case where the nominee is still the legal spouse of the officer at the time of the revocation of the nomination, it is the responsibility of the nominator to inform the nominee of the revocation of the nomination.

G.F. 595