Form of Application for Final Payment of General Provident Fund Balance

(Retirement / Resignation / Removal / Transfer of Balance death Cases)

TO BE FILLED BY THE APPLICANT

To

The Accountant General (A&E)

Andhra Pradesh, Hyderabad.

(Through the Head of Office in case of Non-Gazetted and through the Head of the Department in case of Gazetted Officers)

1.  Name of the Subscriber : BUDUMURU SAKUNTALA
(in capital letters) Employee ID : 0105936
Cell No. : 9573106801

2.  Date of Birth : 30.05.1954

3.  Designation and Office to which : OFFICE SUBORDINATE,
attached GOVT. JUNIOR COLLEGE,
NARASANNAPETA,
SRIKAKULAM DIST.

4.  G.P.F. Account No. with : 001-064-0144.
Department suffix

5.  Residential Address of slip is : BUDUMURU SAKUNTALA,
enclosed W/O B.V. NARASIMHAM LATE,

D.No. 9-1-76, OPP - KILLIVARI VEEDHI,

GOVT. JUNIOR COLLEGE ROAD,

AMADALAVALASA,

SRIKAKULAM DIST. PIN - 532185.

6.  Copy of the latest Account Slip is : ACCOUNT SLIP FOR THE YEAR
enclosed 2012-2013 ENCLOSED

7.  i) Date of Retirement : 31.05.2014
or
ii) Date of Resignation : DOES NOT ARISE
or
iii) Date of Voluntary Retirement : DOES NOT ARISE
iv) Date of dismissal / removal / : DOES NOT ARISE
Compulsory Retirement /
invalidation

8.  Particulars of Offices worked during the last 03 years :

Name of the Office / Address / Working During the Period / Designation
From / To
GOVERNMENT JUNIOR COLLEGE, / NARASANNAPETA (POST), SRIKAKULAM (DIST). / 05.07.2008 / TILL TODATE / OFFICE SUBORDINATE

9.  Office / Treasury at which : SUB-TREASURY OFFICE,
payment is desired NARASANNAPETA, SRIKAKULAM DIST.

10.  If Payment is desired outside the : DOES NOT ARISE
place of last duty enclose the :
following documents
a) Personal Marks of Identification : 1. --
2. --
b) Two specimen Signatures : 1. --
2. --
c) Left / Right hand thumb : --
impression in case of illiterate
claimants

11.  Certificate :
i) I have not resigned from the Government Service to take up appointment in another department of State Government / Central Government or under a body, corporate owned or controlled by the State or Central Government.

Note :- This certificate is to be furnished only by a subscriber who resigned from Government Service. If resigned to take up appointment elsewhere, the information regarding transfer of balance may be given in the form prescribed in the Annexure
ii) I hereby undertake that no appeal shall be preferred by me against my dismissal / removal / compulsory retirement / invalidation.

iii) I hereby undertake to refund any excess payment arising out of clerical error in the settlement of G.P.F. claim.

12.  In case of death the following particulars may be furnished.
a) Date of death (Copy of death : DOES NOT ARISE
certificate to be enclosed)
b) Religion of deceased Govt. : --
Servant
c) Details of the surviving members: --
of the family on the death of the
subscriber are furnished below

Sl. No. / Name / Relationship with the subscriber / Date of Birth / Marital Status as on the date of death of the subscriber

Place : NARASANNAPETA

Date : 25.04.2014 Signature of the Subscriber / Claimant


For Use of Head of the Office / Head of the Department

The Final Withdrawal Application is forwarded to the Accountant General, Andhra Pradesh, Hyderabad for authorizing the balance.

13.  Certified that the particulars furnished above have been verified with reference to office records and are found correct.

14.  The last fund deduction was made from her pay for the month of JANUARY,2014 vide this office Bill No 79/2013-2014 Dated .01.2014 for Rs.77436/- / Rs.63326/- (Rupees Seventy Seven thousand Four hundred and Thirty Six / Sixty Three thousand Three hundred and Twenty Six only) Cash Voucher No.0106-4278 of Sub-Treasury, Narasannapeta the amount of deduction towards G.P.F. subscription being Rs.6000/- And recovery on account of refund of advance Rs.Nil.

15.  Details of G.P.F. deductions made from the subscriber’s salary during the last 12 months immediately preceding the date of retirement (in the proforma appended to G.O.Ms.No.216 Dated 14.06.1986) are enclosed.

16.  Certified that he / she was neither sanctioned Temporary Advance nor any Part-Final Withdrawal from his / her Provident Fund Account during the 12 months immediately preceding the date of his / her quitting service / proceeding on leave preparatory to retirement of thereafter.

(or)

17.  Certified that the following Temporary Advance, Part-Final Withdrawals were sanctioned to his / her and drawn from his/ her Provident Fund Account during the 12 months preceding the date of his / her quitting service / proceeding on leave preparatory to retirement of thereafter.

Sl. No. / Amount of Advance / Part-Final Withdrawal / Date / Voucher No.
NIL

18.  Certified that no amount was withdrawn / the following amounts were withdrawn from his / her Provident Fund account during the 12 months preceding the date of his / her quitting service / proceeding on leave preparatory to retirement of thereafter for payment of insurance premia or for the purchase of a new policy.

1.  Policy No. and Name of Insurance

2.  Sum Assured

3.  Particulars of premia paid from G.P.F.

Yours Faithfully,

Station : NARASANNAPETA

(Signature with date and designation with Postal address)


ANNEXURE

TRANSFER OF BALANCE

In case of absorption in other Departments / Other State Governments / Public Sector Undertakings furnish the following information

i) Date of Absorption :

ii) Is absorption on permanent basis :

iii) Is Absorption without breaks :

iv) In case of breaks of service :
whether it is limited to the joining
time allowed on transfer

v) Is the Absorption with the :
approval of State Government

vi) Accounts Officer to whom the :
balance is to be transferred and
the new G.P.F. Account No.
Allotted by him