Form – 10B / (Part–I)
FORM OF APPLICATION FOR FINAL PAYMENT OF BALANCE IN THE PROVIDENT FUND
ACCOUNT OF A SUBSCRIBER TO BE USED BY THE NOMINEES OR ANY OTHER CLAIMANTS
WHERE NO NOMINATION SUBSISTS.
To
The Principal Accountant General (A&E), West Bengal,
(Through the Head of the Office)
Sir,
It is requested that arrangements may kindly be made for the payment of the
accumulations in the Provident Fund Account of Late : ___________________________.
The necessary particulars required in this connection are given below :–
1. Name of the Govt. Servant :
2. Date of birth :
3. Post held by the Govt. Servant :
4. Date of death :
5. Proof of death in the form of a death :
Certificate issued by the Municipal
Authorities, etc. if available
6. Provident Fund Account No. allotted :
to the subscriber
7. The designation and address of the D.D.O. under whom the subscriber served last is
______________________________________________________________________
__________________________________________ and the name and address of the
accredited Treasury is ___________________________________________.
8. Details of the nominees alive on the date of death of the subscriber, if a nomination
subsists :–
Name of the Nominee Relationship with the Share of the nominee
subscriber
1.
2.
3.
4.
9. In case of nomination is in favour of person other than a member of the family, the
details of the family if the subscriber subsequently acquired a family :–
Name of the Nominee Relationship with the Age on the Date
subscriber
1.
2.
3.
4.
Contd….P/2
–:2:–
10. In case no nomination subsists, the details of the surviving members of the
family on the date of death of the subscriber. In the case of a daughter or of a
daughter of a deceased son of the subscriber married before the death of the
subscriber, it should be stated against her name whether her husband was
alive on the date of death of the subscriber :–
Name Relationship with Age on the Date
the subscriber
1)
2)
3)
4)
11. In the case of amount due to a minor child whose mother (widow of
subscriber) is not a Hindu, the claim should be supported by Indemnity Bond
or Guardianship Certificate, as the case may be ____________________________
12. If the subscriber has left no family and no nomination subsists the names of
persons to whom the Provident Fund money is payable (to be supported by
letters of probate or succession certificate etc.) :–
Name Relationship with Age on the Date
the subscriber of death
1)
2)
3)
4)
13. Religion of the claimant (s) _______________________________________________
Yours faithfully,
State : (Signature of claimant)
Full name and address
Dated :
Contd….P/3
–:3:–
FORM – 10B / (Part–II)
(For use by the Head of the Office/Department)
Forwarded to the Principal Accountant General (A&E), W.B., for necessary
action. The particulars furnished above have been duly verified.
1. The Provident Fund Account No. of
Late __________________________________________ (as verified from the annual
statements furnished to him/her) is _________________________________
2. He / She died on _______________. A death certificate issued by the Municipal
Authorities, etc. has been produced / is not required in this case as there is
no doubt about his / her death.
3. The last fund deduction was made from his / her pay for the month of
_______________ Drawn in this office Bill No. ______________ dated ____________
for ₹ ____________ (Rupees ___________________________________________) Cash
Voucher No. _______________ of _________________________________ Treasury,
the amount of deduction being ₹ _______________ and recovery on account of
Refund of advance ₹ _______________
4. Certified that he / she was sanctioned / not sanctioned refundable advance(s)
from his / her Provident Fund Account during the 12 months immediately
preceding the date of his / her death :–
Amount of Advance G.O. No. & Date Token No. & Date
1)
2)
3)
4)
Certified that he / she was sanctioned / not sanctioned Part final
withdrawals from his / her Provident Fund Account during the 12 months
immediately preceding the date of his / her death :–
Amount of withdrawal G.O. No. & Date Token No. & Date
1)
2)
3)
4)
Contd….P/4
–:4:–
*5. It is certified that no demand / following demands of Government is / are due
for recovery from the incumbent.
6. Certified that he / she was sanctioned / not sanctioned any amount (not
exceeding 90% of balance standing at his / her credit in terms of Finance
Department (Audit Branch) Memo. No. 11830–F dated 05.11.1993 during 12
months immediately preceding this date of his / her retirement / death. The
detail of which has been mentioned below :–
Amount of withdrawal G.O. No. & Date Voucher/Token No. & Date
(Signature of the Head of the Office / Department)
* Certificate to be furnished in case of Contributory Provident Fund only.
