Form of Application for Final Payment of
General Provident Fund Balance
[Retirement / Compulsory Retirement / Voluntary Retirement / Resignation/ Dismissal
/Removal/invalidation/ Transfer of Balance or Death Case etc.]
TO BE FILLED IN BY THE APPLICANT
To
The Accountant General (A&E),
Andhra Pradesh & Telangana Hyderabad.
(Through the Head of office in case of Non-Gazetted and Through Head of the
department in case of Gazetted officers)
I. (i) Name of the Subscriber (in capital letters) :
Emp ID. (7 digit)
(ii) Personal Mobile No :
(iii) Mail id :
(iv) Aadhar Card No. :
(v) Bank Account Details :
(a)Account Number
(b) Name of the Bank
(c) Branch
(d) IFSC code
2. Date of Birth :
3. Designation and office to which attached :
4. GPF Account No. with Departmental Suffix :
5. Details of Nimination (As per Rule 7 & appendix-R)
FORM OF NOMINATION
I hereby nominate the person mentioned below, who is a member of my family as defined in
Rule 2 of the General Provident Fund (Telangana) Rules to receive the amount that may stand to my
credit in the Fund, in the event of my death before that amount has become payable or having become
payable, has not been paid:-
Name and address Relationship Age Contigencies on Name, address and relationship
Of nominee With subscriber the happening of the person, if any, to whom
which the the right of the nominee shall
nomination shall pass in the event of his
become invalid predeceasing of the subscriber
Dated this day of 20 at
Two Witnesses to Signature Signature of the Subscriber
1)
2)
6. Residential address of the claimant: Present Address:
Permanent Address:
7. Copy of the latest Account slip is enclosed: YES/NO
8. i) Date of Retirement : or
ii) Date of resignation : or
iii) Date of voluntary Retirement : or
iv) Date of dismissal/removal/Compulsory Retirement/invalidation
9. Particulars of offices worked during the Last 3 years.
Name of Office & Address Working during the period Designation
10. If payment is desired out-side the place of :
Last duty enclosed the following documents
a) Personal marks of identification
b) Two specimen signatures.
c) Left/Right hand thumb impression
(in case of illiterate claimants)
11. CERTIFICATES:
i) I have not resigned from Government Service to take up appointment in another
department of State Government/ Central Government or under a Body
Corporate owned or controlled by the state or Central Government.
ii)
Note: This certificate is to be furnished only by a subscriber who resigned from
Government service. If resigned to take up appointment elsewhere, the
information regarding transfer of balance may be given in the form prescribed in
the Annexure.
iii) I hereby undertake that no appeal shall be preferred by me against my
dismissal/removal/compulsory retirement/invalidation)
iv) I hereby undertake to refund any excess payment arising out of clerical error in
the settlement of G.P.F. Claim.
12. In case death the following particulars may be furnished.
a) Date of death :
(Copy of death certificate to be enclosed
b) Religion of Deceased Government :
c) Details of the surviving members of :
the family on the date of death of
the subscriber are furnished below
[Link] Name Relationship Date of birth Marital Status as on the
with Date of death of the
subscriber subscriber
Place: Signature of the
Date Subscriber Claimant
FOR THE USE OF HEAD OF THE OFFICE/HEAD OF THE DEPARTMENT
The final withdrawal application is forwarded to the Accountant General, Andhra Pradesh,
Hyderabad, for authorizing the balance.
13. Certified that all the particulars furnished above have been verified with reference to
office records and are found correct.
14. The last fund deduction was made from his/her pay for the month of …………….Vide this
Office Bill No……………………….Dt………………………………for
Rs…………………………..(Rupees……………………………………………………………….)cash voucher
No……………………………………………..of Treasury, the amount of deduction towards G.P.F
subscription being Rs…………………….and recovery on amount of refund of advance
Rs…………………………….
15. Details of G.P.F. Deduction made from the subscriber’s salary during the last 12 months
immediately preceding the date of retirement (in the proforma appended to G.O. Ms.
No. 216. Dated 4-6-1986.
16. Certified that he/she was neither sanctioned any temporary advances nor any part –
final withdrawal 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.
OR
17. Certified that the following temporary advance part-final withdrawals were sanctioned
to him / her and drawn 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.
Part-final withdrawal
1.
2.
18. Certified that no amount was withdrawn/the following amounts were withdrawn 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 there-after
for payment of insurance premia or for the purchase of a new policy
1. Policy No. and Name of Insurance Company
2. Sum Assured
3. Particulars of Premia paid form G.P.F.
Yours faithfully,
Station: SIGNATURE
With date and Designation
Date : Official Mobile /Phone No.
DDO ID:
ANNEXURE
TRANSFER OF BALANCE:
In case of absorption in other Departments other state Government/Public/sector under
takings Furnish the following information.
I. Date of absorption :
II. is absorption on permanent basis :
III. is absorption without breaks in service :
IV. in case of break in service whether it is limited to
joining time allowed on transfer :
V. Is the absorption with the approval of State :
Government
VI. Accounts Officer to whom the balance as to :
be transferred and the new G.P.F. Account
No. allotted by him
FW APPLICATION INSTRUCTIONS
For GPF Subscribers (Accounts maintained by [Link]):
How to fill GPF (final payment) details
GPF final withdrawal details can be filled only after furnishing particulars for
pension. (A.G. authorised or State Audit authorised)
Ensure that subscriber particulars (compulsory) are furnished against relevant fields viz;
a) Employee I.D. assigned by Treasury.
b) Name of the subscriber in full as per the service register.
c) Father’s name or Husband’s name in case of a female employee as per records.
d) Religion of the employee as per records.
e) Date of birth as recorded in service register.
f) Designation & office where the subscriber worked/ working.
g) Date of retirement (superannuation/voluntary retirement/compulsory retirement) or
invalidation or resignation or removal/dismissal from service.
h) Date of death (In case of death of the subscriber) Copy of death certificate to be enclosed
to the F.W. application.
i) Name of the claimant in case of death of the subscriber. (Should be the nominee or eligible
family member as per the definition under Rule.2 of GPF Rules)
j) Personal mobile number of the subscriber/claimant. (If exists)
k) Land line phone number with STD code. (If exists)
l) Personal e-mail I.D. of the subscriber/claimant.
m) Address for communication in full including Door No & street (essential for urban areas)
and PIN code.
n) Address after retirement.
Now fill up GPF details for final payment
o) Select the correct suffix (appearing in the GPF account statement) from the list and enter
in the appropriate field provided.
p) Enter GPF Account Number as mentioned in the GPF account statement. (Enclose copy of
latest available statement to the F.W. application)
q) Furnish details of office from which retired/last worked.
r) Furnish last fund deduction details including details of STO/DTO/PAO
s) Furnish (compulsory) particulars of GPF withdrawals (T.A/PFW) during last 12 months.
(Certificate or Nil statement counter signed by the GPF loan sanctioning authority
is must in the F.W. application)
t) Furnish particulars of employment during last 3 years of service.
u) Furnish list of Family members along with age as on DOD of the subscriber, relationship
and marital status.
In death cases: This list should contain all family members including pre-deceased,
along with dates of death of the pre-deceased. However, GPF shares are to be claimed /
recommended only to the eligible family members. Forwarding authorities should not
recommend GPF shares to ineligible family members like major sons, married daughters
along with other eligible family members and at the same time, should not eliminate any
eligible family member like parents and minor children of the subscriber. Guardian in
respect of minor children where ever natural guardian is not there should be appointed by
the DDO. Date of marriage in case of second or subsequent marriage should be
furnished. Mentioning about first wife (whether not alive or divorced) is a must in these
cases. Guidelines under Rule 2 and 30 of GPF Rules should be followed for determining
eligibility.
Special attention to be given by DDOs in respect of cases involving judicial orders and
they should be forwarded with specific remarks to avoid needless correspondence.
Attested copies of all relevant documents should be enclosed to the F.W. application.
No Demand Certificate
Dated_____________
Certified that the Government dues towards the following items are recoverable from
Sri. _____________________________ Designation _____________________________.
Office of the Superintendent of Police,
has been retired on pension
from
1. House Building loan with :
Interest
2. Motor Car/Cycle Loan :
3. Advance Leave Salary :
4. Advance Salary on transfer :
5. Other Government dues :
6. Electric Department Fee etc :
7. House rent or any other Departmental :
Dues
8. Mint and Workshop charges :
9. Telephone Department fees :
10. Motor khana Amera hire for car etc. :
11. Miscellaneous :
12. Life Insurance :
13. G.P.F :
Signature and Designation
Of the officer
