OFFICE OF THE DISTRICT & SESSIONS JUDG: APPLICATION NEW DELHI DISTRICT Name of the Subscriber 2. Sle, Dio, Wio 3. GPR. Ale No. 4. Designation ; 5. Basic Pay 6. Date of Joining service & : Date of superannuation 7 Balance at credit ofthe subscriber on the date of application as under (Closing balance as per statement for the year. Gi) Credit ROM esses tO ‘on account of monthly subscriptions, Gil) Refunds made to the Fund after the closing balance, vide (i) above : . (iv) Withdrawal during the period from (v) Net balance at credit on date of application 8. Amount of withdrawal required 9. (a) Purpose for which the withdrawal is required : (b) Rule under which the request is covered : 10, Whether any withdrawal was taken for the same purpose eatlier. If so, indicate the amount and the year 11, Name of the Accounts Officer maintaining the Provident Fund Account * Please do submit utilization certificate within 10 days from the date of receiving of withdrawal amount 7 ACCOUNTANT GENERAL REVENUES Dated : NEW DELHI, DISTRICT (Signature of Applicant) Name: Designation: Employee Code Section’ Branch “a