APPLICATION FOR FINAL CLOSURE OF GENERAL PROVIDENT FUND ACCOUNT
(Please ensure that all the relevant particulars are given along with certificates, where necessary to avoid delay in settlement of the claim)
1 Name of the Subscriber (in Block letters)
2 Designation
3 GPF Account Number with Departmental Suffix
4 Date of Birth
5 Office to which attached
6 Residential Address after retirement
7 Date of entry into service
8 Event necessitating closure of account
8a Retirement on Superannuation
8b
Voluntary Retirement (Copy of orders to be enclosed)
8c
Resignation (attach a copy of the orders of
acceptance of resignation
8d
Dismissal/Removal/Compulsory Retirement / Invalidation Date (i) Have you preferred an appeal?
(ii) If yes, date of its disposal / withdrawal
(iii) If no, date of expiry of appeal time (iv) If no appeal has been preferred
give an undertaking that no appeal will be preferred in future 8e Death Date
(i) Has the subscriber filed any nomination? (in original) (ii) If no or if the nomination has been rendered null and void, please furnish the details of the surviving family members on the date of death of subscriber in the format given below Sl. No
Name
Relationship subscriber
with the
1
2
3
4
(iii) If any of the nominee die after the subscriber but before receiving payment
Page 1 of 5
(vide note 3 under Rule 30 (ii) Please or Succession Certificate) (iv) If there is no nomination and if the subscriber has left no family to whom should the money be paid? (Enclose letter of Probate or Succession Certificate) 8f Transfer of Balance
(v) Date of absorption on permanent basis Organisation to which transferred /joined on permanent basis Is absorption on permanent basis? (vi) Is the absorption with the approval of State Government? If so, details of orders may be furnished (vii) Accounts Officer to whom the balance is to be transferred 9 Details of Insurance policy financed from the GPF
Stock Number
Policy
Sum Name Number
Assured
Amount of
Date of Premium
Maturity Date of Payment
of Insurance Company
10 Name and address of offices served during the last 3 years
Name of the Office Address Period of service
Designat ion
11 Particulars of Last Fund Deduction
12
Period during which subscriber was on EOL/ Suspension or any other leave period during which no subscription was recovered
13.
Details of Advances / withdrawals in the last 12 months
90% Part Final Withdrawal
Name of withdrawal
Sanction order No & Date
Amount
Date and place of payment
Voucher Number
(i) Temporary Advance (ii) Part Final Withdrawal
iii) 90% of PFW (as per G.O.535, Govt. Lr.
Page 2 of 5
140075 / Allowances 93-1 Fin Dated:15.1.93 14 Religion of the subscriber
15
Office/Treasury/Sub-Treasury at which GPF payment is desire Whether you are a self drawing officer Drawing Pay in the scale of pay of (Strike out whichever is not applicable) If, Yes (a) Treasury at which GPF payment is desired (b) Enclose the following
(i) Personal Marks of identification (ii) Specimen signature (or) Left/right hand thumb and fingers impression Office/Treasury/Sub-Treasury at which GPF payment is desired
16
I hereby undertake to refund any excess payment arising out of clerical errors in the settlement of GPF claims
Station: Signature of the Claimant
Date:
FOR USE BY HEAD OF OFFICE/DEPARTMENT
Certified that all the particulars furnished above have been fully verified with reference to office records and are found correct.
Certified that no advance /withdrawal from General Provident Fund was granted during the last 12 months except those detailed in item (14) ABOVE
Station:
Date:
Signature of Head of Office Head of Department
Page 3 of 5
ANNEXURE-I
Name: Thiru / Tmt / Selvi
Account No.
Place of Payment:
Month & Year
Gross amount of the bill
T.No.& Date
March
April
May
June
July
August
Sep
Oct
Nov
Dec
Jan
Feb
Total
Subs Refund Total Bill No
Page 4 of 5
Net amount of the bill
ANNEXURE –II
Name :
Designation :
Drawing Officer :
Place of Payment :
Nature of Withdrawal Amount Date and place of payment
Final Closure Rs.
Page 5 of 5