FORM OF APPLICATION FOR FINAL PAYMENT OF GENMERAL

PROVIDENT FUND BALANCE

(Retirement / Resignation / transfer of Balance or Death Cases)
TO BE FILLED IN BY THE APPLICANT

To
The Acccountant General (A. & E)
Andhara Pradesh Hyderabad.

(Through the Head of Office in Case of Non-Gazeted and through Head of the
Department in Case of Gazetted Officers)

1. Name of the Subseriber :

(in capital letters)

2. Date of Birth :

3. Designation and Office which Attached :

4. G.P.F.Account no with Departmental Suffix :

5. Residential Address of the Claimant :

6. Copy of the latest Account slip in enclosed :

7. i) Date of retirement :

OR

ii) Date of Resignation :

iii) Date of Voluntary retirement :

iv) Date of dismissal / removal/compulsory :

Retirement / Invalidation

8. Particulars of Office workded during the last

3 years. :

Working during the period

Name of the Office Address from________ to _________ Designation
9. Office / Treasury at which payment is desitred :

10. If payment is desired outside the place of last

Duty enclose the following documents :

a) Personal marks Identification :

b) Two Specimen Signatures :

c) Left hand thum impressions :

11. CERTIFICATES :

i) I hae not resigned from Government service to take up appointment in

another Department of State Government/Central Government of under a
Body Corporated owned or Controlled by State or Central Government.

NOTE:- 1) This certificate is to be furnished only by a subscriber who resigned from

Government Service. If resigned to take up appointment else where the
Information regarded transfer of balance may be given from prescribed in the
Annexure.

ii) I here by undertake that no appeal shall be preferred by me against my

dismissal removal / compulsory retirement invalidation

(This certificate is to be furnished only in case of dismissal /

removal/compulsory retirement/invalidation)

iii) I here undertake to refund any excess payment arising out clerical error in the
settlement of G.P.F. Claim.

12. in case of death the following particulars may be furnished :

a) Date of death
(copy of death certificate to be enclosed :
b) Religion of deceased Government Servant :

b) Details of the surving members of the family on the :

Family on the date of death of the subscriber are
Furnished below.
 STATEMENT SHOWING DEDUCTIONS FROM GENERAL PROVIDENT FUND IN RES/O SRI______________________________________________________

DESIGNATION_____________________________

Month & Gross Amount of Net amount of the Place & date of Huzur Voucher
Slno. year
G.P.F Amount Deducted Total
the bill bill Encashment no.
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