FORM OF APPLICATION FOR FINAL PAYMENT OF GENERAL PROVIDENT FUND
BALANÇE
(Retirement/Resignation/Transfer of Balance or Death Cases)
(TO BE FILLED IN BY THE APPLICANT)
To
The Principal Accountant Generai (ARE),
Andhra Pradesh & VJAYAWADA.
(THROUGH THE HEAD OF OFFICE IN CASE OF NON-GAZETTED AND THROUGH HEAD OF THE
DEPARTMENT IN CASE OF GAZETTED OFFICERS)
1. () Name of the Subscriber (in Capital
Letters)
Ermp. ID (7 digit)
(ii) Personal Mobile No.
(ii) Mail id
(iv) Aadhar Card No
(v) PAN NO
2. Date of Birth
3. Designation and Office to which
attached
4. G.P.F. Account No. with Department
suffix
5. Details of Nomination filed:(As per
Rule 7)
6 Residential Address of the Claimant:
Present Address
Permanent Address
7. Copy of the Latest, account-slip is Yes enclosed
enclosed
8. (i) Date of Retirement
Or
ii) Date of Designation
Or
iii) Date of Voluntary retirement |:
Or
iv) Date of dismissal/removal/
compulsory retirement/invalidation
9 Particulars of Offices worked during Yes furnished Below
the last three years
Working during the period
Name of Ofice Address From Designation
To
10. Office/Treasury at which payment is
desired
10. (A) If payment is desired outside the
place of last duty enclose the
following documents
a. Personal mark Identification |:
b. Two Specimen Signatures 1
2.
c. Left Right Hand thåmb impression
11. CERTIFICATES department of
Service to take up appointment in another
I. I have not resigned from Government under a Body, Corporate owned or controlled by the State
State Government/Central Government of
of Central Governmert.
ii.
subscriber who resigned from Government Service.
NOTE: This Certificate is to furnished only by a Information regarded transfer of balance may be
elsewhere the
If resigned to take yp appointment
given from prescribed in the annexure.
preferred by me against my dismissal removal or
li. Ihereby yndertake that no appeal shall be
compulsory or retirment invalidation)
settlement of
payment arising out of clerical error in the
0V. I hereby undertake to refund any excess
G.P.F. laim.
12. In case of Death the following
particulars may be furnished
a. Date of Death (Copy of Death
Certificate to be enclosed)
b. Religion of Deceased
Government Servant
C. Details of the suryiving members
of the family on the date of death of
the subscriber are furnished below:
(copy of Family Members Certificate
issued by the Revenye Department)
Material Status as on the
Relationship date of death of the
SI. with the Date of Birth
Name
No. subscriber
subscriber
3 4 5
1
Place: Signature of the Subscriber/Claimant
Date:
FOR THE USE OF THE OFFICE/HEAD OF THE DEPARTMENT
Andhra Pradesh, General,
The Final withdrawal application is forwarded to the Accountant
Hyderabad for authorizing the balance.
been verified with reference to office
13. Certified that al the particulars furnished above have
records and are found correct.
month of
14. The last fund deduction was made from his/her pay the
Vide this office BIlINo. ,dated for Rs.
Gross: Rs. Net: Rs.
,Cash Voucher No. of Treasury,
(Rupees
Cash Voucher No. dt. of
subscription being Rs,
the amount of deduction towards G.P.F.
advance Rs.
And recovery on account of refund of
Details of G.P.F. deduction made from the subscriber's salary during the last 12 months immediately
15. proceeding the date of retirement (in the proforma appended to [Link].216, dt.04.06.1986) are
enclosed.
Certified that he/she was neither sanctioned and temporary advance nor any part-final with drawal from
16. his/her provident fund account during the 12 months immediately proceeding the date of his/her quíting
service/proceeding on leave preparatory to retirement or thereafter.
Certified that the following temporary advance part-final with drawals were sanctioned to him/her and
17. drawan from his/her provident Fund Account during the 12 months immediately proceeding the date of
his/her quitting service/proceeding on leave preparatory to retirement or thereafter.
Amount of advance part final withdrawal Date Voucher No.
[Link].
Station: Yours faithfully,
Date:
(Signature)
With date and designation
Official Mobile/Phone No.
DDO ID:
AN NEXURE
Transfer of Balance:
NIL
i. Date of Absorption
i. Is absorption on permanent Basis? NIL
ii. Is abSorption without breaks in service? NIL
iv. In case of break in service whether it is limited to joining NIL
time allowed on transfer
V. Isthe absorption with approval of State Governrnent? If NIL
Yes, Copy of the order may be enclosed.
vi. Accounts Officer to whom the balance is to be transferred and the NIL
new GPF Account No. allotted by him:
