Form of Application For Final Payment of Balances in The General Provident Fund Account To The Account General Karnataka, Bangalore

Form 6 (A)
(For Gazetted Officers)

FORM OF APPLICATION FOR FINAL PAYMENT OF BALANCES IN THE
GENERAL PROVIDENT FUND ACCOUNT
To
The Account General
Karnataka, Bangalore.
Through ………………………………………………… (the Head of Office/Department)
Sir,
I am due to retire/have retired/preceed on leave preparatory to retirement …………..…….
month/have been discharged/dismissed/have resigned finally from Government Service and my
resignation has been accepted with effect from ………………………..……….. forenoon/afternoon.
2. I have not opted for the continued retention of my Provident Fund money in the fund
in terms of the (O.M. No. FD 25 S.P.F. 58, dated 15th December 1958) as extended from time to
time. I, therefore, request, that the entire amount at my credit with interest due under the rules
may be paid to me through …………………………. Treasury Sub-Treasury. My Provident Fund
Account No. is ………………
OR
I have opted for the continued retention of my Provident Fund money in the Fund in terms
of the (Official Memorandum No. FD 25 S.P.F. 58, dated 15th December 1958) as extended from
time to time and option has been forwarded vide letter No. …………………………… dated
……………………. Is attached. I request that a sum of Rs. ………….…… may be paid to me in
terms of para of that letter through …………….………….. Treasury/Sub-Treasury, my Provident
Fund Account No. is …………….
3. A sum of Rs. ……………….…… (Rupees ……………………………………………….) was last
deducted as Provident Fund subscription and recovery on account of refund of advance from pay
bill for the month of …………………..……… for Rs. ……………..………………………. encashed
………………………. …………………………… at ……………………… Treasury/Sub-Treasury.
*4. My specimen signature in duplicate, duly attested by another Gazetted Officer of
Government is enclosed.
5. I certify that I have neither drawn any temporary advance nor made any final
withdrawal from my Provident Fund Account during the 12 months immediately preceding the
date of my quitting service/proceeding on leave preparatory to retirement or thereafter.
OR
Details of the temporary advances drawn by me/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.
[P.T.O.
2
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 I hereby certify that no amount was withdrawn/the following amounts were withdrawn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 preceding the date of
my quitting service proceeding on leave preporatory to retirement or thereafter for payment of
Insurance premia or for the purchase of a new policy.
Amount Date
1.
2.
7. The particulars of the 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.
3.
4.
Yours faithfully,
Station:
(Signature)
Date: Name and Address
* Para applies only when payment is desired at a treasury other than the one at the
District Head quarters where the subscriber last served otherwise it may be struck out.
CERTIFICATE BY THE HEAD OF OFFICE/DEPARTMENT
1. It is certified after due verification with reference to the records in my office, that no
temporary advance/final withdrawal was sanctioned to 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.
OR
2. It is certified after due verification with reference to the records in my office, the
following temporary advance/final withdraws were sanctioned to the applicant 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 or thereafter.
Amount of advance withdrawal Date Voucher No.
1.
2.
3. It is certified that no demands following demands of Governments are due for recovery.
(Signature of the Head of Office/Department)

Certificate No. 3 to be furnished in the case of Contributory Provident Funds only.
Govt. Press, Bangalore-P5

Form of Application For Final Payment of Balances in The General Provident Fund Account To The Account General Karnataka, Bangalore

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Form of Application For Final Payment of Balances in The General Provident Fund Account To The Account General Karnataka, Bangalore

Uploaded by

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Form 6 (A)

(For Gazetted Officers)

Through ………………………………………………… (the Head of Office/Department)

Amount of advance Date

(Signature of the Head of Office/Department)

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