Application for Closing of Dsop Fund Account And

APPENDIX ‘A’

IN (PAY) 238 A GEN FORM
Casuality LEAVE – ACCUMULATION –ACCUMULATION
UNIT
GX. NO :GX Date : AMPM : Dt of occ :
Maker : Maker Date : Authorizer : Authorize Date :
Sr.No. / Per.No. / Name / Rank / Acc Days / For Year / Authority
01.
Details :
PERMITTD TO ENCASH ACCUMULATED ANNUAL LEAVE VIDE NAVPAY SIGNAL DTG 071244/JUL DETAILS OF ACCUMULAD LEAVE AS FOLLOWS :
YEAR : NO OF DAYS
______
UP TO YEAR 2014- 315 DAYS
2015-0
Issuing authority
(Unit Stamp)
AUTHORITY

APPENDIX ‘B’

APPLICATION FOR CLOSING OF DSOP FUND ACCOUNT AND

PAYMENT OF BALANCE

PART I

Sir,

I, Service/P.No______Rank ______Name______

Due to retire / have retired proceeding on leave pending retirement / have been,discharged / dismissed from service with effect from______I request that my subscription to provident Fund be discontinued from pay of ______

I request that final payment of balance in the provident fund be made to me through my bankers as shown below for credit to my account No. ______or may be paid in cash or sent by money order at the following address at my expense.(delete whichever is inapplicable).

BankersResidential address

______

The under mentioned Life Insurance Policies financed by me from my Provident Fund may be released .

Policy No. ______

Certificate that :-

(1)I have not drawn any temporary advance of final withdrawal from my Provident Fund account during the last one year immediately preceding the date of release from Service

(2)I have withdrawn from my fund a/c the following amount during the last one year preceding the date of release :-

Nature of withdrawal / Amount / Date of drawal
Temporary advance
Final withdrawal

Date :Yours faithfully,

-2-

PART II

Received a sum of Rs……………………………(Rupees...……………………only for full and final settlement of may provident fund.

Date : (Duly Pre-receipted over

(01 Rupee Revenue Stamp

Signature

PART III

The details furnished by the individual are correct as per Fund Ledger Account as on ………... Details of nominee are furnished below as per document :-

Name : ______DOB : ______

Date :For Logistics Officer-in-Charge Naval Pay Office

PART IV

Checked and passed for payment of Rs …………………..(Rupees ………………………………………………………………..only).

Date :

CDA (N) Mumbai

PART V

Payment of Rs …………………………..(Rupees …………………………………………only) made by cheque / Draft /M.O.No ……………………………..through imprest of ……………...... attached on Fund Account Ledger Card.

For Logistics Officer-in- charge

DateNaval Pay Office Mumbai

In lieu of IAFA 115

APPENDIX ‘C’

CONTINGENT BILL

Expenditure on account of TERMINAL GRATUITY

Incurred by (Rank)______(Name)______(P.No.)______

Authority :-GOI, MOD letter No. 2(5) 187/D(Revision Services) dated Oct 87 and GOI, MOD. Dept. of Ex-Servicemen Welfare , New Delhi letter 17(4)/2008(2)/(Pen/Pol) dated 12 Nov 08 and IHQ, MOD(N) letter______Dated______

…………………………………………………………………………………………………………Details of Expenditure Amounts

…………………………………………………………………………………………………………On account of “Terminal Gratuity” on completion Short Service Commission without break in Service for the period from ______

To______(Total of service______Years______Months______Days).Rs.______

Certified that :-

The amount in question has not been claimed / received by me.

Signature______

Name ______Rank______P.No.______Rs.______

Net Amount due (in words) Rupees______only)

Banker Address

Name of Account Holder (s)______

Name of the Bank______Bank A/C No.______

IFSCCode______MICRNo.______Branch Code______

ECS Code______

Bank Branch Address______

______

Re 1/-Revenue Stamp

Received Payment Signature______Name ______Rank______P.No.______

COUNTERSINGED BY THE COMMANDING OFFICER

Place:______

Date :______

Enclosures :-

Forwarded to :-

The Logistics Officer-in-Charge

(for O/DEMOB Section)

Naval Pay Office

Mumbai-400023

(Unit Stamp)

CERTIFICATE BY THE OFFICER APPENDIX ‘D’

I______(Rank)______(Name)______(P.No.) was granted short service commission in the indian navy w.e.f______.I have been released from naval service on ______after completion of ______years ______months___days vide IHQMOD (N) PDOP letter______

2.I hereby certify the following :-

(a)That I had no break in service.

(b)That I have filed the following claims for TA/DA/LTC advances drawn during the last 06 (six) months of service.

(i)LTC claim forwarded vide ______dated______.

(ii)TY Duty claim(s) forwarded vide ______dated______.

(c)That I am not holding any Govt. Accommodation on my name as on date.

(d)That the particulars of Furlough Leave during my entire service are as follows:-

(i)______days w.e.f______

(ii)______days w.e.f______

(e)That I had No lower deck service/______years of lower deck service.

(f)That I had No service as a Sailor/Sepoy/Airman/Civil Govt. Servant.

(g)That I have not taken any employment during my Terminal leave.

(h)That I have relinquisbec my duties as (SSC) on ______

(j)That my Post Retirement Address and email ID for the purpose of all correspondence is as follows : ______

(k)That my Bank particulars for the purpose of all retirement benefits is as follows:-

Name of Account Holder(s)______

Name of the Bank ______Bank A/C No.______

IFSCCode______MICRNo______Branch Code______

Bank Branch Address______

Signature______

Name______Rank______P.No.______

COUNTERSINGED BY THE COMMANDING OFFICER

Place : ______

Date : ______

(Unit stamp)

Genform

APPENDIX ‘E’

IN (PAY) 238 A GEN FORM
Casuality MISCELLANEOUS – RETIREMENT FROM ACTIVE SERVICE – RETIRED/RELEASE SSC OFFICER
UNIT
GX. NO :GX Date : AMPM : Dt of occ :
Maker : Maker Date : Authorizer : Authorize Date :
Per.No / Name / Rank / Leave Years / Leave Days / Term.Days / Authority
IHQMOD (N) / DOP LETTER ………..
Details :
THE ABOVE MENTIONED SHORT SERVICE COMMISIONED OFFICER IS RETIRED FROM ACTIVE SERVICE W.E.F. …………VIDE IHQMOD(N) / DOP LETTER …………DATED ………..PROCEEDING .___DAYS OF BAL OF ____FOLLOWED BY ___DAYS TERMINAL LEAVE WEF ___APR ____.CEASED TO DRAW RIK(O).
POST RETIREMENTADDRESS ……………………………………………………………
PHONE NO …………………
EMAIL ………………………
Issuing authority
(Unit Stamp)
AUTHORITY

APPENDIX ‘F’

INS Angre

ShahidBhagat Singh Road

Mumbai – 400023

File : 240/16

Date

NO DEMAND CERTIFICATE

(Para 79 , Financial Regulation Part – II for the Indian Navy)

CERTIFICATE OF COMMANDING OFFICER

This is to certify that to the best of my knowledge and belief there are no Public dues / claim outstanding againt Lt Cdr ______. The Offricer is being released from Service w.e.f. ____

Unit StampCommanding Officer

SERVICE EXTRACT APPENDIX ‘G’

Rank ______Name ______P.No. ______

SI NO / UNIT / RANK / FROM / TO / DESIGNATION
01. / INS Mandovi / SLt / Aug 2002 / Dec 2002 / Under Training
02. / INS Mysore / SLt / Dec 2002 / Dec 2002 / Under Training
03.. / INS Shivaji / SLt / Dec 2002 / Jan 2003 / Under Training
04. / INS Valsura / SLt / Jan 2003 / Dec 2003 / Under Training
05. / INS Savitri / SLt / Dec 2003 / May 2004 / Under Training
06. / INS Valsura / SLt / May 2004 / Oct 2004 / Under Training
07. / Naval Dockyard (V) / Lt / Oct 2004 / Apr 2007 / Asst. Manager IT
08. / INS Betwa / Lt / Apr 2007 / Aug 2008 / Weapons Maintenance Officer
09. / FTTT(MB)/Angre Addl / Lt / Aug 2008 / May 2009 / Dy Manager GGASW
10. / INS Kalinga / Lt Cdr / May 2009 / Aug 2011 / Oi/c Brahmos Technical Position
11. / NTG(MB)/Angre Addl / Lt Cdr / Aug 2011 / Aug 2012 / Deputy Oi/c

(______)

Rank & Name ______

P.No. ______

COUNTERSIGNED

(Unit Stamp)

APPENDIX ‘H’

CERTIFICATE OF ‘NO EMPLOYMENT DURING TERMINAL / ANNUAL LEAVE

01.This is to certify that, I______taken up any employment during my terminal leave / annual leave.

02.My Permanent residential address and bank particulars are as given below :-

Permanent Address

Bank Details

Email id :

Station :

Date :(______)

Rank & Name

P.No.

COUNTERSIGNED

Unit Stamp

Commanding Officer

Place :

Date :