APPLICATION FOR FINAL PAYMENT OF BALANCES IN APEPDCL GENERAL PROVIDENT FUND ACCOUNT SIXTH SCHEDULE (See Regulation. 38 (3) FORM "A" (For Employees of Class I and II Services) To The Chief General Manager (HRD), A.P.E.P.D.C.L, Corporate Office, VISAKHAPATNAM. "THROUGH PROPER CHANNEL" Sir, 1. I am due to retire/ have retired/have proceeded on leave preparatory to retirement for months/have been discharged/ dismissed/compulsorily retired/ invalided/have resigned finally from EPDCL service and my resignation has been accepted with effect from _____________________A.N. 2. A Sum of Rs. _______________ (Rupees _____________________________ was last deducted as General Provident as Provident Fund Subscription and recovery on account of refund of advance from my pay bill for the month of __________ encashed on_________vide C.B.Vr.No. Dt.___________ 3. My specimen signatures, induplicate, duly attested by another employee of Class-I and II is enclosed. 4. My General Provident Fund A/c No. is ________________ I desire to receive payment through my office i.e., ______________________________________ 5. I certify that I have neither drawn any Temporary Advance nor made any Part final withdrawal from my Provident Fund account during the 12 months immediately proceeding the date of my quitting service/proceeding on leave preparatory to retirement or thereafter. Details of the temporary advances drawn by me/part final withdrawals made by me from my provident fund account during the 12 months preceding the date of my quitting service/proceeding on leave preparatory to retirement or thereafter are given below: Amount of Advance Date 1. 2. 3. 6. I hereby certify that no amount was withdrawn / the following amounts were withdrawn by me from my provident fund account during the 12 months immediately proceeding the date of my quitting service/proceeding on leave preparatory to retirement or thereafter for payment of Insurance premium or for the purchase of a new policy. Amount Date 1. 2. 3. 7. @ I certify that I have not preferred/will not prefer an appeal against my dismissal/ removal/compulsory retirement/invalidation from service. 8. The particulars of Life Insurance Policies financed by me from the provident fund which are to be released by you are given below : Policy No. Name of the Co. Sum assured 1. 2. Station: Yours faithfully, Date : (Signature of employee) Name and Address _____________________________________________________________________ FOOT NOTE: @ Para 7 applies to employees who are dismissed / removed / compulsorily retired / invalidated from service. CERTIFIED BY THE HEAD OF OFFICE 1. It is certified after due verification with reference to the records in my office, that no Temporary Advance / Part final /Final Withdrawal was sanctioned to the applicant from his / her provident fund account during 12 months immediately proceeding the date of his / her quitting service/proceeding on leave preparatory or retirement or thereafter. OR 2. It is certified after due verification with reference to the records in my office, that the following Temporary Advances/ Part Final Withdrawal / Final withdrawal were sanctioned to and drawn by the applicant 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/withdrawal _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ _ Vr.No. _ _ _ 1. 2. 3. @ It is certified that the employee had appealed against the order of his/her dismissal/removal compulsory retirement/ invalidation from service and final orders on the appeal were passed on _ _ _ _ _ _ _ _ _ but the employee stated in writing _ _ _ _ _ _ _ _ _ _ _ _ _ that he /she had withdrawn his/her appeal. (OR) It is certified that the employee has not preferred an appeal against the order of his/her dismissal/removal compulsory retirement/ invalidation from service and that the time allowed for preferring appeal expired on _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . OR It is certified that the employee has given a declaration in writing that he she will not prefer an appeal against the order of his/her dismissal/removal/compulsory retirement / invalidation from service. (SIGNATURE OF THE HEAD OF OFFICE) @ Certificate No.3 to be furnished in the case of employees who were dismissal / removed / compulsorily retired/invalided from service. UNDER TAIKING I, ___________________________________________________________________due to retire on Superannuation / Voluntary retire on ______________________ do hereby agree if any excess payment is made consequent on pay fixation from time to time or G.P.F etc., the same may be recovered from my Terminal benefits. Signature of employee SPECIMEN SIGNATURES Specimen signatures of Sri / Smt. _____________________________________________ due to retire on Superannuation / Voluntary retirement on ________________________ 1. 2. 3. Attested by Enclosures : 1. Application in quadruplicate. 2. Undertaking. 3. Specimen Signatures duly attested by controlling officer. 4. Statement of accumulation duly signed and certified by drawing officer. 5. Latest GPF Original Slip. 6. Retirement order copy.
