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									                                         FORM-A

 APPLICATION FORMS FOR FINAL PAYMENT OF BALANCES IN
     THE PROVIDENT FUND (FOR GAZETTED OFFICERS)

     Form of Application for Final Payment/Transfer to Bodies
Corporate/Other Government of Balances in the ……………..…………
……………….………………………….…… Provident Fund Account.
To
       The Accountant General,
       ……………………………….
       ……………………………….

       (Through ……………………………………………. the Head of Office/Department)

Sir,
            I am to retire/have retired/have proceeded on leave preparatory to retirement for
………………………. for months/have been discharged dismissed/ have been permanently
transferred to ……………………………………….. have resigned finally from Government
service under …..………………………………………Government to take up appointment with
……………………………………….. and my resignation has been accepted, with effect from
…………………………                forenoon/afternoon.   I   joined   service   with   ………………..on
………………………. Forenoon/afternoon.

        2. My provident Fund Account No. is ……………………………………….. .
        3. My specimen signature in duplicate, duly attested by another gazetted officer, is
enclosed.
                                          PART I
        (To be filled in when the application for final payment submitted upto one year prior to
retirement)-

        4. I request that the amount of Rs. ……………………… standing to the credit in my
General Provident Fund Account as indicated in the Accounts statement issued to me for the year
……………….(enclosed) / as appearing in my ledger account being maintained by you, may
please be arranged to be paid to me through …………………… Treasury/Sub-Treasury.

         5. Certified that I had taken the following advances in respect of which …………..
instalments of Rs. …………. Are yet to be repaid to be fund account. I had taken the following
final withdrawals :
               Temporary advances                             Final withdrawals

       1.      ………………………                                      …………………….
       2.      ………………………                                      …………………….
       3.      ………………………                                      …………………….
       4.      ………………………                                      …………………….
        6. Certified that the following amounts were withdrawn by me to finance my Life
Insurance Policy from my provident Fund Account:
        1.      ………………………                                  …………………….
        2.      ………………………                                         …………………….
        3.      ………………………                                         …………………….
        4.      ………………………                                         …………………….


        7. Certified that after the payment of first installment of my Provident Fund balance, I
will apply for the payment of the subsequent installments in Part II of the form immediately on
retirement.

                                                                         Signature of the subscriber.

                                                                             Name and address


              CERTIFICATION BY THE HEAD OF OFFICE/DEPARTMENT

         Certified that the above information has been verified from the records being maintained in
this office and is correct.


                                                            Signature of Head of Office/Department.



                                            PART II
        (To be submitted by the subscriber immediately after his retirement. This Part is also
applicable in the case of subscribers who apply for final payment for the first time after the date of
superannuation, discharge, resignation, etc.)

       4. In continuation of my application for final payment sent to you, vide No.
…………………… , dated ………………. I request that the balance in my Provident Fund
Account may please be paid to me.

                                                OR
        I request that the entire amount at my credit with interest due under the rules may be paid
to me through ……………………… Treasury/ Sub-Treasury / may be transferred to my Provident
Fund Account. My Provident Fund Account No. is ……………………… .

        5. A sum of Rs. ………………. (Rupees ………………………………………………)
was last deducted as Provident Fund subscription and recovery on account of refund of advance
from my pay bill for the month of …………………. For Rs. …………………… en-cashed on
……………….. at …………………………… Treasury/ Sub-Treasury.

       6. I certify that I have neither drawn any temporary advance nor made any final
withdrawal from my Provident Fund Account during the 12 months immediately preceding the date
of my quitting service under ……………………………………. .

                                                 OR
           Details of the temporary advances drawn by me/final withdrawals made by me from
my Provident Fund Account during the 12 months proceeding the date of my quitting service under
………………… Government / proceeding on leave preparatory to retirement or thereafter are
given below:

                Amount of advances                                   Date

       1.       ………………………                                     …………………….
       2.       ………………………                                     …………………….


        7. I hereby certify that no amount was withdrawn/the following amounts were withdrawn
by me from my Provident Fund Account during the 12 months immediately proceeding the date of
my quitting service under ………………… Government / proceeding on leave preparatory to
retirement or thereafter for payment of insurance premia or for the purchase of a new policy.

                Amount of advances                                   Date

       1.       ………………………                                     …………………….
       2.       ………………………                                     …………………….

       8. The particulars of the Life Insurance Policies financed by me from the Provident Fund
which are to be released by you are given below:

            Policy                   Name of the Company            Sum assured
       1. ……………….                  …………………………….                   ……………………
       2. ……………….                  …………………………….                   ……………………
       3. ……………….                  …………………………….                   ……………………
       4. ……………….                  …………………………….                   ……………………

                                                                        Yours faithfully,

       Station :                                          Signature ……………………………

       Date :                                            (Name and address) …………………
                CERTIFICATE BY THE HEAD OF OFFICE/DEPARTMENT

        Forwarded in continuation of endorsement No. ………………… Dated …………………

       1. (a) It is certified after due verification with reference to the records in my office, that
no temporary advance/final withdrawal was sanctioned to the applicant from him/her Provident
Fund Account during the 12 months immediately preceding the date of his/her quitting service
under …………………… Government/proceeding on leave preparatory to retirement or thereafter.

                                                 OR

        2. It is certified that after due verification with reference to the records in my office, the
following temporary advance/final withdrawal were sanctioned to and drawn by the applicant from
him/her Provident Fund Account during 12 months immediately preceding the date of his/her
quitting service under ……………………. Government/proceeding on leave preparatory to
retirement or thereafter.

           Amount of advance/withdrawal    Date                                Voucher number
        1. …………………………...                …………………………….                           ……………………
        2. …………………………..                       …………………………….                     ……………………

        3. It is certified that no demands/following demands of Government are due for recovery.

         4. Certified that he/she has not resigned from Government service with prior permission
of the State Government to take up an appointment in another Department of the Statement
Government or under a Central Government or under a body corporate owned or controlled by the
Central.




                                                      (Signature of the Head of Office / Department)
                                           FORM B

                             FOR NON-GAZETTED OFFICERS

          Form of Application for Final Payment/Transfer to Corporate Bodies/Other
Governments of Balances in the …………….. Provident Fund Account.

To
           The Accountant General,
           ……………………………………….

                   (Through the Head of Office)

Sir,
         I am to retire/have retired/have proceeded on leave preparatory to retirement for
………………………. for months/have been discharged dismissed/ have been permanently
transferred to ……………………………………….. have resigned finally from Government
service under …..………………………………………Government to take up appointment with
……………………………………….. and my resignation has been accepted, with effect from
………………………… forenoon/afternoon. I joined service with ………………..on
………………………. Forenoon/afternoon.

       2. My Provident Fund Account No. is …………………… .

         3. I desire to receive payment through my office/through ………………………………
Treasury/Sub-Treasury. Particular of my personal marks of identification, left hand thumb and
finger impressions (in the case of illiterate subscribers) and specimen signature (in the case of
literate subscriber) in duplicate, duly attested by a gazetted Officer of the Government, are
enclosed:-
                                            PART I
           (To be filled in when the application for final payment is submitted upto one year prior
           to retirement)

          4. I request that the amount of Rs. ……………………… standing to the credit in my
General Provident Fund Account as indicated in the Accounts statement issued to me for the year
……………….(enclosed) / as appearing in my ledger account being maintained by
you…………….. Treasury/Sub Treasury/Head of Office, may please be arranged to be paid to me
as first installment of final payment.

       5. The undermentioned Life Insurance Policies were being financed by me from my
Provident Fund Account :

          Policy number              Name of the Company              Sum assured
       1. ……………….                  …………………………….                     ……………………
       2. ……………….                  …………………………….                     ……………………
       3. ……………….                  …………………………….                     ……………………

       6. After payment of the first installment of my Provident Fund balance, I will apply for
the payment of subsequent installments in Part II of the form immediately on retirement.


                                                                                   Yours faithfully,


                                                        Signature __________________________

       Station _________________________              Name ____________________________
       Date   _________________________            Address ____________________________

       This applies only when payment is not desired through the Head of Office.
                            (FOR USE BY HEADS OF OFFICES)
          Forwarded to the Accountant General _____________________________ for necessary
action.

        2. The Provident Fund Account No. ___________ of Shri/Shrimati/Kumari (as verified
from the Statements furnished to him/her from year to year) is ___________________________ .

          3. He/She is due to retire from Government Service on ________________ .

         4. Certified that he/she had taken the following advances in respect of which ________
installment of Rs. ______________ are yet to be recovered and credited to the Fund Account. The
details of the final withdrawals granted to him/her are also indicated below:

                 Temporary advances                           Final withdrawals
          1.     ………………………                                    …………………….
          2.     ………………………                                    …………………….
          3.     ………………………                                    …………………….
          4.     ………………………                                    …………………….


         5. Certified that the following amount were withdrawn from his/her account to finance
the Life Insurance Policy:

          1. …………………                ………………….                      ……………………
          2. …………………                ………………….                      ……………………
          3. …………………                ………………….                      ……………………
          4. …………………                ………………….                      ……………………


                                                           ______________________________
                                                                 Signature of the Head of Office
                                            PART     II
(To be submitted by the subscriber immediately after his retirement. This Part is also applicable in
the case of subscribers who apply for final payment for the first time after the date of
superannuation, discharge, resignation, etc.)

        In continuation of any application, dated ……………. for the final payment of the
Provident Fund balances, I request that the entire balance at my credit with interest due under the
rules may be paid to me.
                                                OR
        I request that the entire amount at my credit with interest due under the rules may be paid
to me/transferred to …………………… .

                                                          Signature ………………………………..
                                                          Name ……………………………………
                                                          Address ………………………………….


                             (FOR USE BY HEAD OF OFFICES)

        Forwarded to the Accountant General ……………………… for necessary action/in
continuation of endorsement No. ………………………. Dated …………………….. .

        2. He/She has finally retired/will proceed on leave preparatory to retirement for
……………….. months/has been discharged/dismissed/has been permanently transferred
to…………………… /has resigned/finally from Government service / has resigned service under
………………….. Government to take up appointment with ………………… and his/her
resignation has been accepted with effect from …………………… forenoon/afternoon. He joined
service with ………………….. on ………………….. forenoon/afternoon.

       3. The last fund deduction was made form his/her pay in this office Bill No. …………,
dated …………….. for Rs. …………… (Rupees ……………………) cash voucher No. ……….
of ………………….. Treasury, the amount of deduction being Rs. …………………. and recovery
on account of refund of advance Rs. ………………… .

        4. Certified that he/she was neither sanctioned any temporary advance or any final
withdrawal from his/her Provident Fund Account during the 12 months immediately preceding the
date of his/her quitting service under ……………………. Government/proceeding on leave
preparatory to retirement or thereafter.

                                                  OR
        Certified that the following temporary advances/final withdrawals were sanctioned to
him/her and drawn from his/her Provident Fund Account during the 12 months immediately
preceding the date of his/her quitting service under ……………………. Government/proceeding
on leave preparatory to retirement or thereafter.

           Amount of advance/           Date                          Voucher number
           Withdrawal
        1. …………………                  ………………….                         ……………………
        2. …………………                  ………………….                         ……………………
        3. …………………                  ………………….                         ……………………
         5. Certified that no amount was withdrawn/the following amounts were withdrawn from
his/her Provident Fund Account during the twelve months immediately preceding the date of
his/her quitting service under ……………………. Government/proceeding on leave preparatory to
retirement or thereafter for payment of Insurance Premia or for the purchase of a new policy.

          Amount                  Date                           Voucher number
       1. …………………                 ………………….                       ……………………
       2. …………………                 ………………….                       ……………………
       3. …………………                 ………………….                       ……………………

       6. It is certified that no demands/following demands of Government are due for recovery.

        7. Certified that he/she has not resigned from Government service with prior permission
of the State Government to take up an appointment in another Department of the State Government
or under a Central Government or under a body corporate owned or controlled by the Central.


                                                      ________________________________
                                                      Signature of Head of Office/Department
                                           FORM ‘C’

                    Form of application for Final Payment of Balances in the
                       Provident Fund Account of a SUBSCRIBER to be
                          used by the nominees or any other claimants
                                 where no nomination subsists

To
       The Accountant General,
       …………………………………………

       (Through the Head of Office)

Sir,
        It is requested that arrangements may kindly be made for the payment of the accumulations
in the ………………………………. Provident Fund Account of Shri/Shrimati
…………………………………………………. The necessary particulars required in this
connection are given below:

1.     Name of the Government servant ……………………………………….
2.     Date of birth ……………………………
3.     Post held by the Government servant ……………………..
4.     Date of death …………………………..
5.     Proof of death in the form of death
       certificate issued by the municipal
       authorities, etc., if available ……..

6.     Provident Fund Account No. allotted
       to the subscriber………..

7.     Account of Provident Fund money
       standing to the credit of the subscriber
       at the time of his death, if
       known…………………….

8.     Details of the nominees alive on the
       date of death of the subscriber at the
       time of his death, if known ………..


          Name of the               Relationship with             State of the nominee
          Nominee                   the subscriber
       1. …………………                   ………………….                       ……………………
       2. …………………                   ………………….                       ……………………
       3. …………………                   ………………….                       ……………………
9.       In case the nomination is in favour of a person other than a member of the family, the
details of the family if the subscriber subsequently acquired a family.

            Name                     Relationship with                Age on the date
                                     the subscriber                   of death
        1. …………………                   ………………….                          ……………………
        2. …………………                   ………………….                          ……………………
        3. …………………                   ………………….                          ……………………

        10. In case no nomination subsists, the details of the surviving members of the family on
the date of death of the subscriber. In the case of daughter or of a daughter of a deceased son of the
subscriber, married before the death of the subscriber, it should be stated against her name whether
her husband was alive on the date of death of the subscriber.


            Name                     Relationship with                Age on the date
                                     the subscriber                   of death
        1. …………………                   ………………….                          ……………………
        2. …………………                   ………………….                          ……………………
        3. …………………                   ………………….                          ……………………

        11. In the case of amount due to a minor child whose mother (widow of subscriber) is not
a Hindu, the claim should be supported by Indemnity Bond or Guardianship Certificate, as the case
may be.

         12. If the subscriber has left no family and no nomination subsists, the names or persons to
whom the Provident Fund money is payable (to be supported by letter of probate or succession
certificate, etc.)

            Name                     Relationship with                Address
                                     the subscriber
        1. …………………                   ………………….                          ……………………
        2. …………………                   ………………….                          ……………………
        3. …………………                   ………………….                          ……………………




        13. Religion of the claimant(s).
14.      The payment is desired through the office of ……………………………… / through the
……………………………… Treasury/Sub-Treasury. In this connection the following documents
duly attested by a Gazetted Officer in service/Magistrate are attached.

        (i) Personal marks of identification.
        (ii) Left/right hand thumb or finger impression (in the case of illiterate claimants)
        (iii) Specimen signatures in duplicate (in the case of literate claimants)




                                                                                 Yours faithfully,

        Station ………………….                                                     (Signature of claimant)
        Date ……………………                                                       (Full name and address)


                     (FOR USE OF HEAD OF OFFICE/DEPARTMENT)

        Forwarded to the Accountant General …………………….. for necessary action. The
particulars furnished above have been duly verified.

   2. The Provident Fund Account No. ……………….………… of Shri/ Shrimati/ Kumari
……………………………… (as verified from the annual statements furnished to him/her) is
…………………………… .

         3. He/she died on ……………….. . A death certificate issued by the Competent
authorities has been produced/is not required in this case as there is no doubt about his/her death.

       4. The last fund deduction was made from his/her pay for the month of
………………………………… drawn in this office Bill No. …………….. dated …………….. for
Rs. …………… (Rupees ……………………………) cash voucher No. ………………….. of
………………………. Treasury, the amount of deducting being Rs. ………………. and recovery,
on account of refund of advance of Rs. …………………

                                                  OR

         Certified that he/she was neither sanctioned any temporary advance nor any final
withdrawal from his/her Provident Fund Account during the 12 months immediately the date of
his/her death.

        Amount of advances/           Date and place of                 Voucher Number
        Withdrawal                    encashment

1.      ……………………….                        …………             ………..            …………………

2.      ……………………….                        …………             ………..            …………………

3.      ……………………….                        …………             ………..            …………………
        6. Certified that no amount was withdrawn/the following amounts were withdrawn from
his/her Provident Fund Account during the 12 months immediately preceding the date of his/her
death for payment of insurance premia or for the purchase of a new policy.

       Policy number and                 Amount             Date            Voucher number
       name of the company

1.     ……………………….                        …………             ………..             …………………

2.     ……………………….                        …………             ………..             …………………

3.     ……………………….                        …………             ………..             …………………

                                    no demand
       7. It is certified that -------------------------- of Government are due for recovery.
                                 following demands

       8. Certified that no advance/following advance sanctioned is due for recovery.



                                                       [Signature of the Head of Office/Department]
FORMS OF NOMINATION

   I. When the subscriber has a family and wishes to nominate one member thereof.

       I hereby nominate the person mentioned below, who is a member of my family as defined
   in Rule 2 of the General Provident Fund Rules, to receive the amount that may stand to my
   credit in the Fund in the event of my death before that amount has become payable, or having
   become payable has not been paid.

Name and Relationship          Age Contingencies on the      Name, address and relationship of
address of with subscriber         happening of which        the person/persons if any, to
nominee                            the nomination shall      whom the right of the nominee
                                   become invalid.           shall pass in the event of his
                                                             predeceasing the subscriber.




   Dated this ………………………………………… day of ………………………..200

   At …………………………………………….

   Two Witness to signature

      1. …………………………………………………………..

      2. …………………………………………………………..


                                                                       Signature of subscriber.
II. When the subscriber has a family and wishes to nominate more than one member
thereof.

        I hereby nominate the persons mentioned below, who are members of my family as
defined in Rule 2 of General Provident Fund Rules, to receive the amount that may stand to my
credit in the event of my death before that amount has become payable or having become
payable has not been paid, and direct the said amount shall be distributed among the said persons
in the manner shown against their names.

Name and address of Relationship Age         Amount     of    Contingencies    Name, address and
nominees            with                     share      of    on         the   relationship of the
                    subscriber               accumulations    happening of     person/persons if any,
                                             to be paid to    which      the   to whom the right of
                                             each             nomination       the nominee shall pass
                                                              shall become     in the event of his
                                                              invalid.         predeceasing       the
                                                                               subscriber.




   Dated this ………………………………………… day of ………………………..200

   At …………………………………………….

   Two Witness to signature

       1. …………………………………………………………..

       2. …………………………………………………………..


                                                                         Signature of subscriber.
III. When the subscriber has no family and wishes to nominate one person.

       I, having no family as defined in Rules 2 of the General Provident Fund Rules hereby
nominate the person mentioned below to receive the amount that may stand to my credit in the
Fund, in the event of my death before that amount has become payable, or having become
payable has not been paid:

Name and Relationship          Age Contingencies on      Name, address and relationship
address of with subscriber         the happening of      of the person/persons if any, to
nominee.                           which           the   whom the right of the nominee
                                   nomination shall      shall pass in the event of his
                                   become invalid.       predeceasing the subscriber.




   Dated this ………………………………………… day of ………………………..200

   At …………………………………………….

   Two Witness to signature

       1. …………………………………………………………..

       2. …………………………………………………………..


                                                                     Signature of subscriber.
IV. When the subscriber has no family and wishes to nominate more than one person.

        I, having no family as defined in Rules 2 of the General Provident Fund Rules 1985,
hereby nominate the persons mentioned below to receive the amount that may stand to my credit
in the Fund, in the event of my death before that amount has become payable, or having become
payable has not been paid, and direct that the said amount shall be distributed among the said
persons in the manner shown below against their names:

Name and address of Relationship Age        Amount     of   Contingencies    Name, address
nominees            with                    share      of   on         the   and relationship
                    subscriber              accumulations   happening of     of             the
                                            to be paid to   which      the   person/persons if
                                            each            nomination       any, to whom the
                                                            shall become     right    of    the
                                                            invalid.         nominee      shall
                                                                             pass in the event
                                                                             of             his
                                                                             predeceasing the
                                                                             subscriber.




   Dated this ………………………………………… day of ………………………..200

   At …………………………………………….

   Two Witness to signature

       1. …………………………………………………………..

       2. …………………………………………………………..

                                                                       Signature of subscriber
Office of the ………………………………..                          Statement of particulars for allotment          of Please read carefully the instructions
……………………………………………...                                  Provident Fund Accounts Numbers                 to printed on the reverse before filling in the
……………………………………………..                                   compulsory subscribers for the                     form.

Head of Account to which pay and allowances are                                                           Name of Fund………………..
debited ……………………………
Sl. Name         of Name        of Date       of Date of Designation             Emoluments Monthly rate       Month from Remarks To        be
No. Government subscriber’s         birth     of joining                                    of                 which              filled in by
      Servant       father/husband subscriber.   service.                                   subscription       subscription       Accountant
      (Subscriber)                                                                          (in     whole      to                 General’s
                                                                                            rupees)            commence.          Office.
                                                                                                                                  Account
                                                                                                                                  No.
                                                                                                                                  allotted.
1     2               3                4              5           6              7             8               9            10




No……………………….. Dated………….....                                                  No. ………………………… Dated…………..
 Forwarded in duplicate to the Accountant General for necessary action.       Returned to ………………………… Account Nos. allotted may be
The Government servants whose names are included in their statement           intimated to the subscribers and also noted in the Service Books,
are required to joint the ………………Fund under the ………………                         nominations and other official records. In all correspondence connected
rules of Government of …………………….. Their names have not been                   with Provident Fund of any subscriber, the account number should be
included in the previous statements and they are not already members of       quoted. Receipt of nominations at Sl. Nos. ………………… is hereby
any provident Fund (Nominations are enclosed as mentioned in the              acknowledged.
remarks column.)
Certified that all the employees whose names are shown above are                                         Accounts Officer
eligible to subscribe to the provident fund in accordance with the relevant
rules.                                                      Office of the Accountant General …………....
                                                            …………………………………………………
                              (Head of Office) ………………………….. …………………………………………………
(Reverse of the Form)

Instructions for filling the statement:

      (a) This Form should be used only in cases where subscription to the Fund is compulsory.
      (b) Separate forms should be used for different provident funds, e.g., General Provident Fund, Contributory Provident Fund, etc.
      (c) Separate Forms should be used for persons whose pay and allowances are debited to different Major and Sub-Major Heads of
          Account.
      (d) Name of the Fund may be filled in by suitable words (e.g.) General Provident Fund (Central), Contributory provident fund (India) etc.
      (e) The Statement should be sent in duplicate. It should include permanent Government Servant who joined service in the previous
          month are required to join the fund compulsorily on entry into Government Service and temporary Government servants who will
          complete one year’s continuous service or otherwise become eligible to subscribe to the provident fund, three months hence.
      (f) Column 3 Husband’s name (instead of father’s name) may be given in respect of married female subscribers indicating the position.
      (g) Column-7 Dearness pay, if any, may be distinctly shown.
      (h) Nominations of gazetted officers appointed directly to gazetted post whose service records are maintained by the Accountant General
          shall be sent to the Accountant General’s office for safekeeping. In case of non-gazetted government servants and gazetted officers
          whose pay and allowances are drawn by Head of the office in Establishment bills, the nominations will be kept by the Head of Office.

								
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