FORM
2
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 nominee
Relationship with the
Share of the nominee
subscriber
1
.
..
..
2
.
..
..
3
..
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 the Age on the date of death
subscriber
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 would be stated against her name whether her husband was
alive on the date of death of the subscriber:
Name Relationship with the Age on the date of death
subscriber
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
the Address
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:
1.Personal Marks of
identification
2.Left/Right hand thumb or
finger impression (in the case of illiterate claimants)
3.Specimen signatures in
duplicate (in the case of literate claimants)
Yours Faithfully,
Signature of Claimant
Name
.
Address
.
Station
.
Dated
..
(FOR
USE BY HEADS OF OFFICES)
Forwarded to the Accountant- General
..
for necessary action. The particulars furnished above have been duly verified.
2. The Provident Fund Account no
. of
Shri/Smt
..( 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 the his/her death.
4.
The last fund deduction was made from his/her pay in this Office bill
no
.., Dated
., for Rs
. (Rupees
) cash
voucher no
of
Treasury, the amount of deduction being Rs
and
recovery on account of refund of advance 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 of Advance/withdrawal Date Voucher No.
1
.
..
2
.
..
3
.
..
7.
It is certified that no demands / following demands of the Government are due
for recovery.
(Signature
of Head of Office/ Department)
Note: -
Certificate No. 7 to be furnished in the case of CPF only.