Try Form No 425-A

FORM (A)

 (For Gazetted Officer)

(FORM OF APPLICATION FOR FINAL PAYMENT OF BALANCES)

IN THE……………………………………………. PROVIDENT FUND ACCOUNT

 

TO

         THE ACCOUNT GENERAL

         UTTAR PARDESH, ALLAHABAD

         (Through the Head Office / Department)

Sir,

1.           I am due to retire/ have retired/ have proceeded on leave preparatory to retirement………………………………months/  

have been discharge/ dismissed / have resigned finally from Government service and my resignation has been accepted with effect from………………………………………forenoon / afternoon.

 

2.           I have not opted for the continued retention of my provident Fund Money in the Fund in terms of the Vitta Vibhag

        office Memorandum no. G-2-2445 / X-511- 1958, dated January 16, 1960. I, theref0re, request that the entire amount at

        my credit with interest due under the rules may be paid to me through…………………………Treasury / Sub-Treasury.

        Provident Fund Account no. is……………………………………

 

OR

 

         I have not opted for the continued retention of my provident Fund Money in the Fund in terms of the Vitta Vibhag Office Memorandum no. G-2-2445/X-511-1958, dated January 16,1960 and my option has been forwarded, vide letter no………………………………………………….dated ………………………………/ is attached. I request that a sum of Rs…………………………………………………………………………may be paid to me in terms of para 2 of that letter through……………………………………………….Treasury, Sub-Treasury, My provident Fund Account no. is…………….

3.           A sum Rs………………………..(Rupees………………………)was last deducted as Provident Fund subscription and

recovery on account of refund of advance from my pay bill for the month of…………………….Rs………….Enchased

on………………………….at Treasury / Sub-Treasury.

4.           My specimen signature, in duplicate duly attested by another Gazetted Officer of Government, is enclosed.

5.           I certify that I have neither drawn any temporary advance nor made any final withdrawal from my provident Fund Account during the 12 months immediately proceeding the date of my quitting service / proceeding  on leave preparatory to retirement or thereafter.

 

OR

 

        Details of the temporary advances drawn by me / final withdrawals made by me from my provident Fund Account during the 12 months proceeding the date of my quitting service / proceeding on leave preparatory to retirement or thereafter are given below:

 

        Amount of Advance

        (1)

        (2)

 

        Para 4 applies only when payment is desired to treasury other than one at the District Headquarters where the subscriber last served otherwise it may be struck out.

 

 

 

6.           I hereby certify that no amount was withdrawn / the following amount were withdrawn by me from my provident Fund Account during the 12 months immediately preceding the date of my quitting service / proceeding on leave preparatory to retirement or thereafter for payment of Insurance premium or for the purchase of a new policy:-

 

              Amount                                                                                                    Date

     

       (1)

  

       (2)

7.           The particulars of the Life Insurance Policies financed by me from the provident Fund which are to be released by you are given below:

 

                Policy no.                                           Name of the Co.                          Sum assured

        

          (1)

  

          (2)

  

          (3)

 

           (4)

 

 

Station                                                                                                                                   Yours faithfully,

Date                                                                                                                                        Signature……………………………………

                                                                                                      Name and address…………………………..     

                                                                              

CERTIFICATE BY THE HEAD OF OFFICE / DEPARTMENT

1.        It is certified after due verification with reference to the records in my office, that no temporary advance / final with drawal was sanctioned to the applicant 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

 

2.        It is certified after due verification with reference to the records in my office, that the following temporary advance / fianl withdrawals were sanctioned to and drawn by the applicant 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 / withdrawals                                          Date                        Voucher no.

       (1)

 

       (2)

3.        It is certified that no demands / following demands of Government are due for recovery.

 

 

                                                                                             Signature of the Head of

                                                                                             Office / Department

 

 

 

 

                This deed of indemnity is made on the …………………… …………………………………… date of …………….1999 corresponding to Saka Samvat the   ……………………day of …………. 19 … by Sri ……………………………………. S/o ……………………… Resident …………………… ………………………..of (Bounden) In Favour of the Governor of  Uttar Pradesh (called "the Governor") ………………………………… ……………………………………………………… whereas:-

1-             The bounden above name was/is in the service of the Government of Uttar Pradesh (Called "Government") as …………………………….. (designation) in ……………… ………………………… …………….… (name of office).

2-                   The Bounden above name has retired/is due for retirement on ……………………………………………………

3-             A 'No demand certificate ' is required to be issued in Favour of the Bounden by ...…………………… before sanction of pension, gratuity etc. to the Bounden but the said certificate could not be issued so far and the serenity of records fot that purpose is likely to take further time.
4-             The Government is willing to sanction pension and gratuity etc. to this Bounden of condition that the Bounden shell execute a bond, being these presents, to indemnify and save harmless the Government from any loss which the Government may incur by reason of any moneys found due against the Bounden within a period of two years from the date of retirement of the Bounden.

Now this deed witnesses—

1-             In consideration of Government agreeing to sanction pension and gratuity ect. to the Bounden before issue of 'No demand certificate in this Favour, the Bounden here by covenants with the Governor that the Bounden shall pay on demand to the Government all moneys which may be discovered; within a period of two years from the date of retirement of the Bounden; to be

2-             Any amount due under this deed may; on the certificate of ……………………… which shall be final; conclusive and dinging on the Bounden; be recovered from him as arrears of land revenue.

                 In witness to the above written  bond and the conditions there of the Bounden has signed hereunder on the day and year first above written.

                The stamp duty on this instrument will be borne by the Government.

  

Signed by Bounden Witness :-

1…………………………………

Address

2…………………………………

Address