Form of application for Final Payment of Balances in the Provident Fund Account of a SUBSCRIBER to be used by the nominees or any other claimants where no nomination subsists. To The Accountant General, ----------------------------- (Through the Head of office) Sir, It is requested that arrangements may kindly be made for the payment of the accumulations in the -------------------- Provident Fund Account of Shri/Shrimati-----------------------------.The necessary particulars required in this connection are given below:- 1. Name of the Government servant-------------------------. 2. Date of birth -------------------------------------- 3. Post held by the Government 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. Amount of provident Fund money standing to the credit Of the subscriber at the time of his death,if known.------------- 8. Details of the nominees alive on the date of death Of the subscriber, if a nomination subsists: Name of the Relationship with Share of the Nominee the subscriber nominee 1. ------------------ ---------------------- ------------------- 2. ------------------ ---------------------- ------------------- 3. ------------------ ---------------------- -------------------- 4. ------------------ ----------------------- --------------------- 9. In case the nomination is in favour of a person other than a member of the family, the details of the family, if the subscriber subsequently acquired a family: Name Relationship with Age on the date The subscriber of death 1. ----------------------- ----------------------- ---------------------- 2. ----------------------- ----------------------- ---------------------- 3. ---------------------- ----------------------- ---------------------- 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 of death 1. ---------------------- --------------------------- ----------------------- 2. ---------------------- --------------------------- ----------------------- 3. --------------------- --------------------------- ----------------------- 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 letter of probate or succession certificate, etc.). Name Relationship with Address The subscriber 1. ------------------------ -------------------------- ------------------------- 2. ------------------------ -------------------------- ------------------------- 3. ------------------------ -------------------------- ------------------------- 13. Religion of the claimant(s) ... ... 14. The payment is desired through the office of------------------/through the ---------Treasury/ Sub-Treasury. In this connection the following documents duly attested by a Gazetted officer in service./Magistrate are attached:- (i) Personal marks of identification ----------- (ii) Left/right hand thumb or finger impression (in the case of illiterate claimants) ------------------------------ (iii)Specimen signatures in duplicate (in the case if literate claimants) ------------------ Yours faithfully Station----------- Dated------------ (Signature of claimant) (Full name and address) (FOR USE OF HEAD OF OFFICE/DEPARTMENT) Forwarded to the Accountant-General -----------------------for necessary action. The particulars furnished above have been duly verified. 2. The Provident Fund Account No.-------------- of Sh./Smt./Km.--------------------(as verified from the annual statements furnished to him/her)is ------------------- 3. He /She died on ----------------A death certificate issued by the Municipal authorities has been produced/is not required in this case as there is no doubt about his/her death. 4. The last fund deduction was made from his/her pay for the month of ----------------drawn in this office Bill No. ------------, dated--------------, for Rs.------------(Rupee's---------) Cash Voucher No.-----------of --------------Treasury, the amount of deduction being Rs.-----------------and recovery, on account of refund of advance of Rs.----------------------- 5. Certified that he/she was neither sanctioned any temporary advance nor any final withdrawal from his/her provident Fund Account during the 12 months immediately preceding the date of his/her death. Or Certified that the following temporary advances/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 death. Amount Date and place Voucher Advances/withdrawals of encashment number 1. ------------------------ --------------------- ----------------------- 2. ------------------------ --------------------- ----------------------- 6. *** 7. It is certified that no demand of Government is/are due for recovery. Following demands 8. Certified that no advance/following advance sanctioned in terms of the Ministry of Finance, Office Memorandum No.10 (3)-E.V. (A)/65,dated the Ist November, 1965,is due for recovery. (Signature of the Head of office/Department) Note -Certificate No 7 to be furnished in the case of CPF only.
