Application For Final Closure of General Provident Fund Account (Please ensure that all the relevant Particulars are given with certificates where necessary to avoid delay in settlement of claim) 1. Name of the Subscriber (in BLOCK LETTERS) : 2. Designation : 3. General Provident Fund account : Number with Departmental Suffix 4. Date of birth : 5. Office to which attached : 6. Residential Address after retirement : 7. EVENT NECESSITATING : CLOSURE OF ACCOUNT A. Retirement Date : B. Resignation / Voluntary retirement : Date (attach a copy of the orders) C. 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 : under taking that no appeal will be preferred in future I hereby undertake that no appeal shall be Preferred by me against my dismissal / removal/ Compulsory retirement / invalidation (cancel whichever is not applicable. 7(D). Death - Date : i) Has the subscriber filed any nomination (If : yes, enclose nomination in original) ii) If No or if the nomination has been : rendered full and void who are the surviving family members on the date of death of the subscriber (Enclose a Legal Heirship Certificate) Name Relationship with The subscriber Age Marital Status i) Did the nominee die after the subscriber : but before receiving payment (vide note 3 under rule 30(ii) ii) If there is no nomination and if the : subscriber has left no family to whom should the money be paid ? (Enclose letters of probate or succession Certificate) 7 (E). TRANSFER OF BALANCE : i) Date of absorption : ii) Is absorption on permanent basis? : iii) Is absorption without break in service? : iv) If No. to (iii) Is break limited to the : joining time allowed on transfer v) Is the absorption with the approval of : State Government vi) Account officer to whom the balance : is to be transferred 8. Details of Insurance policy financed from General Provident Fund Stock Number Policy No. Sum Assured Amount of premium Date of payment Date of maturity Name of Insurance Co. 9. Names and address of offices served during the last 3 years: 10. Particulars of Last Fund Deduction: 11. Details of Advances / withdrawals in the last 12 months period to stoppage of subscription to General Fund. Name of the Address Period of Designation Office Service Pay for month G.P.F. Subscription Recovery Refund Gross Amoun t of bill Net Amount Of bills Date of Encashment Place of Payment Head of Account Voucher No Nature withdrawal Amount Date and place of Vr, No : Temporary Advance : Part Final withdrawal : Life Insurance Policy : 12. Religion of the Subscriber : 13. Office / Treasury / Sub-Treasury which : GPF payment is desired 14. If you are a self drawing officer or you : desire payment outside the place of last duty, enclose the following (i) Personal Marks of Identification : (ii) Speciman signature or left / right : hand thumb and fingers impression 15. I hereby undertake to refund any excess payment arising out of clerical errors in the Settlement of G.P.F. claims Station: Signature of the Claimant Date: (with Name in BLOCK LETTERS) For USE BY HEAD 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 Funds was granted during the last 12 months except those detailed in item (11) above. Station: Signature of Head of Office / Date: Head of Department
