FORM – 10 A
(For all officers other than Group D)
Form of Application for Final Payment of Balance (Rs.........................................) in
the Provident Fund Account,
To
The Accountant General (A&E), W.B.
...............................................................
...............................................................
...............................................................
(THROUGH THE HEAD OF OFFICE)
Sir,
I am due to retire/have retired/have proceeded on leave preparatory to
retirement for ........................... months/have been discharged/dismissed/have
resigned finally from Government Service and my resignation has been accepted with
effect from ................................ forenoon/afternoon.
2. My provident fund Account No. is ...................................., I desire to receive
payment through my office/through the
............................................................Treasury/Sub-Treasury. *Particulars of
my personal marks of identification, photograph, left hand thumb and finger
impressions (in the case of illerate subscribers) and specimen signature (in the case
of literate subscribers), in duplicate, duly attested by a Group-A service officer of the
Government are enclosed.
3. The under mentioned Life Insurance Policies financed by me.
Policy No. Name of the Company Sum assured
1.
2.
4. I have stopped subscription to my Provident Fund Account three months
prior to the date of retirement on superannuation in terms of Government of West
Bengal, Finance Department Memorandum nos. 1991-F dt. 01.03.1999.
Yours faithfully,
Residential Address:-
Station (Signature)
Date:- Name:
Address with mobile number (if subscriber wishes to receive SMS alerts):
* This applies only when payment is not desired through the Head of office
Page:- 2
(For use by Head of Office)
Forwarded to the Accountant General (A&E), W.B. for necessary action.
2. The provident Fund Account No. of Shri/Smt./Kumari
................................................................. (as verified from the
statements furnished to him/her from year to year) is ................................
.
3. He/She has finally retired/will retire/has proceeded on leave preparatory to
retirement for ............................... months/has been
discharged/dismissed/has resigned finally from Government service and
his/her resignation has been accepted with effect from .........................
forenoon/afternoon.
4. He/She has stopped of subscription to his/her Provident Fund Account three
months prior to the date of his/her retirement on superannuation in terms of
Government of West Bengal, Finance Department Memorandum nos. 1991-F
dt. 01.03.1999.
5. The last fund deduction was made from his/her pay in this office Bill No.
......................... ......... dated ........................... for Rs. ........................
(Rupees ................................................................
..................................................................) Cash Voucher No.
.................................................... dt. ................................. of Treasury,
the amount of deduction being Rs. ..................................... and recovery on
account of refund of advance Rs. .................................. .
6. Certified that he/she was sanctioned/not sanctioned any temporary advance
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 Date Voucher No.
1)
2)
3)
4)
Certified that he/she was sanctioned/not sanctioned final/withdrawal final
withdrawals 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.
Withdrawal Date Voucher No.
1)
2)
3)
4)
5)
7. Certified that no amount was withdrawn/the following amounts were
withdrawn from his/her provident fund A/c during the 12 months immediately
preceding the date of his/her quitting service/proceeding on leave preparatory
to retirement or thereafter for the purposes noted below including the one for
payment of insurance premia or for the purpose of a new policy:
Amount Purpose Date Voucher No.
1)
2)
*8. It is certified that no demands/following demands of Government are due for
recovery.
9. It is certified that he/she has not resigned Government Service to take up
appointment in another Deptt. of the State Government or other State
Governments or Central Government or under a body corporate owned or
controlled by Government.
10. Certified that he/she was sanctioned/not sanctioned a one time withdrawal within 90% of
his/her G.P.F. balance within 12 months immediately preceding the date of his/her
retirement on superannuation in terms of Finance Department No. 11830-F dt. 05.11.1993,
the details of which has been mentioned below:
Amount of withdrawal G.O. No. Date Token No. & Date
11. Certified that an amount of Rs. .............................. /due to ROPA for the
year............................ was deposited in his/her G.P.F. A/c No. ......................... vide
Token No./T.V. No. ...................... dt. ..................... and the same amount was not
withdrawn/withdrawn as per details given below:
Amount of withdrawal Date Token No. & Date
(SIGNATURE OF THE HEAD
OF OFFICE/DEPARTMENT)
With Seal
* Certificate No. 8 to be furnished in the case of contributory Provident Fund
only.
[Authority:- Govt. of West Bengal Finance Department Audit Branch letter No. 5906-
F dated 08.05.1984].
