Application form for final payment of Balance in the Provident Fund
FORM G.P.F. 10-A
(for Gazetted Officer)
To
The Accountant General
Tripura, Agartala
Through the Head of Office/Department
Sir,
I am due to retire/have retired/have proceeded on leave preparatory to
retirement for_____________ months/have been discharged/dismissed/ have been
permanently transferred to ___________________________/ resigned finally from
Government service under ___________________________ Government of Tripura
to take up appointment with ____________________ and my resignation has been
accepted with effect from ______________________forenoon/ afternoon. I have
joined service with _________________ on _______________ forenoon/ afternoon.
2. My specimen signature in duplicate, dully attested by another Gazetted officer
is enclosed.
P A R T–I
(To be filled in when the application for final payment submitted up to one year prior
to retirement)
4. I request that the amount of Rs._____________ ( Rupees_______________
______________________________________) standing to the credit in my General
Provident Fund Account as identified in the Accounts Statement issued to me for the
Year _____________ (Enclosed) / as appearing in my ledger account being
maintained by you, may please be arranged to be paid to me
through_____________________ __________________Treasury/Sub-Treasury.
5. Certified that, I had taken the following Advance in respect of which
________________ Installments of Rs.______________ are yet to be repaid to the
Fund Account. I had taken the following final withdrawals: -
TEMPORARY ADVANCES WITHDRAWALS
01.
02.
03.
04.
05.
6. Certified that the following amounts were withdrawn by me to finance my
Life Insurance Policy from my Provident Fund Account : -
01. TEMPORARY ADVANCES WITHDRAWALS
02.
03.
04.
05.
7. Certified that after the payment of first installment of my Provident Fund
balance, I will apply for the payment of a subsequent installments in part – II of the
form immediately on retirement.
Date.
Place.
Signature of the Subscriber
Name_________________________
Address_______________________
CERTIFICATION IN THE HEAD OF OFFICE/DEPARTMENT
Certified that the above information has been verified from the records being
maintained in this office and is correct.
Signature of the Head of Office/
Department
P A R T– II
(To be submitted by the subscriber immediately after his retirement, This part
is also applicable in the case of Subscribers who apply for final payment for the first
time after the date of superannuation, discharge, resignation etc.)
4. In continuation of my application for final payment sent to you, vide No.
.______________________________________ dated ____________ I request that
the balance in my Provident Fund Account may please be paid to me.
OR
I request that the entire amount at my credit with interest due under the rules may be
paid to me through __________________ Treasury/Sub-Treasury/may be transferred
to me Provident Fund Account. My Provident Fund Account
is________________________.
5. A sum of Rs.__________
(Rupees______________________________________) only was last deduction as
Provident Fund subscription and recovery on account of refund of advances from my
pay bill for the month of ________________ for Rs. __________ once paid on
_______________ at_______________Treasury/Sub-Treasury.
6. I certified that, I have neither drawn any temporary advance normade any final
withdrawal from my Provident Fund account during the 12 Months
immediately proceeding the date of my quitting service under _________________
______________________
Details of the temporary advance drawn by me/final withdrawalsmade by me
from my Provident Fund account during the 12 Months proceeding the date
of my quitting service under _________________ Government/proceeding on leave
preparatory to retirement or thereafter are given below.
Amount of Advance Date
1.
2.
7. I hereby certified that, no advance was withdrawn/the followingamounts were
withdrawn by me made by me from my Provident Fund account during the 12
Months immediately proceeding the date of my quitting service under
_______________ Government/proceeding on leave preparatory toretirement or
thereafter for payment of ………………………………… or for the purchase of a
new policy: -
Amount Date
1.
2.
8. The particulars of the Life Insurance Policy financed by me from the
Provident Fund which are to be released by you are given below: -
Policy No. Name of the Company Sum assured
Yours faithfully,
Station Signature
Date Name_____________________
Address_____________
_____________________________________________________________________
Para 4 applies only when payment is …………………………………….other
the one at the District Headquarters where the subscriber last served. Otherwise it may
be struck out.
CERTIFICATE BY THE HEAD OF OFFICE/DEPARTMENT
Forwarded in continuation of endorsement No…………………………………
………………………………. Dated………………………………………
1. (a) It is certified after due verification with reference to the
records in my office, that no temporary advance/final withdrawal
wassanctioned to the applicant from his/her Provident Fund account during the
12 Months immediately proceeding the date of my quitting service
under_________________Government/proceeding on leave preparatory to
retirement or thereafter.
OR
2. It is certified that after the verification with reference to the records
in my office, the following temporary advance/final Provident Fund
account was sanctioned to the applicant from his/her Provident Fund account
during the 12 Months immediately proceeding the date of his/ her
quitting service under _________________ Government/proceeding on leave
preparatory to retirement or thereafter.
Sl. No. Amount of Date Voucher No.
Advance/withdrawal.
3. It is certified that no demands/following demands of Government are
due for recovery.
4. Certified that he/she has not reigned from Government service with
prior permission of the Central Government to take up an appointment in
another Department of the Central Government or under a State Government
or under a corporate ownod or controlled by the State.
(Signature of the Head of
Office/ Department)
* Certificate No.3 to be furnished in the same of Contributory Provident Fund only.
** Please Score out if not necessary.
