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FORM J
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[See Rule 28(5), 39(1), (2) & (3)]
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* APPLICATION FOR CLOSURE OF GENERAL PROVIDENT FUND (KERALA) ACCOUNT
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1Name (in full), office address of Subscriber Account Number and reference number (as indicated in the latest annual account statement received from the Accountant General with Section & Branch:
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(a)
Designation (Specify whether Gazetted or Non-Gazetted):
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(b)Date of Birth:
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(c)Date of joining service :
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(e)Home Address with Contact Number :
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(d)If the subscriber is an employee of the Education Department : whether the subscriber is a Surrendered School Teacher:
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(a)
Office in which the susbscriber is working / worked last :
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(b)
District in which the subscriber is working / worked last:
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(a)
Date of proceeding on leave preparatory to retirement:
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(b)Date of quitting service by retirement / superannuation:
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(c)Statement of option as required in Rule 28(6) [See Note 4 below]:
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(If he / she has already quitted service otherwise specify whether he / she has quitted service by discharge, dismissal, resignation or death etc.):
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5In case of 4 (b) whether he / she has drawn his / her salary for the month immediately preceding the month of retirement, if so, furnish the date of drawal of the salary. :
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6(a)Whether the Statement of deposits and withdrawals after the period, which has been included in the latest Credit Card till the month in which the Provident Fund subscription is discontinued, is furnished.:
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(b)
Periods, if any , during which no subscriptions and refund of advance have been recovered due to Leave without allowance etc. :
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(a)
Number and date of the Bill / Treasury Voucher in which the last Provident Fund deduction was made. (Also indicate the name of the Treasury where the Bill / Vourcher was encashed).:
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(b)
the amount of last fund deductions :-:
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(i)Subscription :
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(ii)Refund of advance:
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(c)Gross amount of the Bill / Treasury Vocuher:
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(d)
Net amount of the Bill / Treasury Voucher:
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(e)Date of encashment of the Bill / Treasury Vocuher :
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8(a)Whether any temporary advance was sanctioned to him / her from his / her GPF (Kerala) account during the twelve months immediately preceding the date of application for closure of the account on his / her quitting service. (If so, indicate the amount of the advance, the number and the date of sanction and the date of drawal of the amount) :
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(b)Whether any non-refundable whithdrawal was sactioned to him / her from his / her PF account during the twelve months immediately preceding the date of application for closure of account on his / her quitting service, (if so, indicate the amount of advance, number and date of sanction and the date of drawal of the amount) :
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9Whether personal marks of identification, left hand thumb and finger impressions and specimen signature in duplicate, duly attested by a Gazetted Officer of the State Government have been furnished. (In respect of a Gazetted Officer, specimen Signature in duplicate, duly attested by another Gazetted Officer alone need be furnished. ):
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10Name of the Treasury / Office through which payment is to be made:
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11A.In the event of death of a subscriber before making final disbursement of the PF amount, furnish also:
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(a)Date of Birth of the subscriber :
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(b)
Date of his / her first appointment in the Government Service:
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(c)Date of death:
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(d)
Whether proof of death in the form of a death Certificate issued by the Municipal authorities or other competent authorities is available. (The proof of death need be insisted upon only in cases of doubt) :
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(e)Whether a valid nomination executed by the subscriber in accordance with the rules exists. [If so, attach the nomination in original] :
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(f)In the case of subscriber who filed his / her nomination while unmarried, whether he / she acquired a family after the submission of the first nomination and whether he / she has submitted a fresh one thereafter. :
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B.If there is no valid nomination, furnish a list of member (s) of the subscriber's family as defined in Rule 2 (c ) of the GPF (Kerala) Rules surviving on the date of death of the subscriber to whom the PF money is payable together with his / her / their name (s), age(s) and respective relationship to the subscriber, with Departmental Enquiry Certificate (DEC). [ in the case daughter(s), indicate whether she / they is / are married or unmarried. If married, furnish whether her / their husband (s) is / are alive ]:
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C.In case whether there is no valid nomitation and where no member of the family of the subscriber as defined in Rule 2 (c ) of the GPF (Kerala) Rules survives, furnish the name(s) of the person(s) to whom the PF money is payable (to be supported by letters of probate or Succession Certificate, etc..):
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12Whether a fresh nomination has been enclosed with the closure application (The subscriber is requried to file a fresh nomination and enclose the same with the closure application) :
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DECLARATION
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I ………………………………………………………………………………………………….. .do hereby declare that the particulars mentioned above are ture. I further declare that I do not / do accept the balance standing to my credit in the GPF (Kerala) Account No: ………………………………………………….. .communicated to me by the Accounts Officer in his Annual Account Statement for the financial year ended on the 31 st March 20 .....................................................................................(here enter the financial year immediately preceding the date of his quitting service)
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Dated Signature of the Subscriber /
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Station:
Nominee(s) / other claimant(s) with full home address
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Date :
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(To be filled in by Head of Office / Depapartment)
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C E R T I F I C A T E S
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(1)Certified after due verification with reference to the records available in my office that Shri. / Smt. …………………………………………………………………………………subscriber to PF Account No: …………………………………………………has proceeded on leave preparatory to retirement with effect from ………................................................................FN / AN will be retiring / has already retired / has been discharged / dismisseed / removed / has resigned finally from Government service with effect from .........................................................FN / AN and his / her resignation has been accepted. He / She has drawn on ........................................................................ his / her salary for the month immediately preceding the month of retirement.
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 Certified also that he / she has not resigned from Government Service with the prior permission of the Government to take up appointment in another department of the State Government or under the Central Government or under any other State Government or under a body corporate owned or controlled by Government or an autonomous organisation, registered under the Socicieties Registration ACT 1860
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(2)Certified further after due verification with reference to the records available in my office that no temporary advance / non-refundable withdrawal was sanctioned to the subscriber from his Provident Fund Account during the 12 months immediately preceding the date of his application for closure of the account / quitting service. Certified also after due verification with reference to the records available in my office that the following temporary advance(s) / non-refundable withdrawal(s) was / were sanctioned to the subscriber from his / her Provident Fund Account during the twelve months immediately preceding the date of his / her application for the closure of PF account / quitting service.
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Amount of temporary
Advance		Amount of non-refundable withdrawalNo. and date of sanctionDate of withdrawalVoucher
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(3)Certified that the last Fund deduction was made from his / her pay for the month of …………………………drawn in this office bill No: …………………………………. dated..............................for ......................... (Rupees ....................................................................................................................of ……………………………………………………………Treasury, the amount of deduction being …………………………………………………..and recovery on account of refund of advance being .........................................................................................................
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(4)Certified also that the entry against items 1, 2, 3 and 7 furnished by the claimant(s) have been verified by me with reference to my office records and found correct.
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(5)Certified also that the entry against column 11 B furnished by the claimant(s) has been verified by me and found correct to the best of my knowledge.