APPENDIX'O'

FORM APPLICATION FOR PART-FINAL WITHDRAWAL OF MONEY FROM THE PROVIDENT FUND FOR HOUSE
BUILDING PURCHASE OR REDEMPTION OF HOUSE AND HOUSE-SITES HIGHER EDUCATION PURPOSES OR
MARRIAGE OR MEDICAL EXPENSES.

1 Name of the subscriber :

2 Designation :
3 Pay :
4 Name of the provident fund Account No. :
Balance at the credit of subcriber on the date of
5
application
:
Note: In the case of part final withdrawal for house building and marriage
purpose as well as purchase of house/house site. The total balance
at the credit of all the provident funds should be taken into account
if the subscriber more than one Provident fund. :

(1) Amount of Part-Final withdrawal already taken : -- Nil --

Balance at credit at the time of making the first

(2)
part final withdrawal.
:

Amount required in the case of construction of

house or for the purchase of a house site the
6
number of instalment in which ti is required
:
should be stated.

The purpose for which the amount is required (a)

if it is for house building for the purpose
7
purchasing a house site or for expenses purpose
:
of repayment of any loan taken under.

(i) For purchasing a house : -- Nil --

(ii) For Construction reconstruction a house : -- Nil --

For redemption of a house for marriage

(iii)
additions or alteration to a house
: -- Nil --

For making additions a alterations to a

(iv)
house
: -- Nil --

(v) For purchase of a hous- site : -- Nil --

For repayment of a loan expressly taken

(vi)
for the purchase of a house-site and
: -- Nil --

(vii) For repayment of any laon taken under : -- Nil --

(B) if it is for higher education : -- Nil --

Relationship with the person (who is

(i) actually dependent on the subscriber for : -- Nil --
whom the withdrawal is required.
 The specifec course taken by the person and the
(ii)
name and place of the institutions.
: -- Nil --

Whether the course is for more than three years

(iii)
and beyond the high school stage.
: -- Nil --

Whether this is the first or the second withdrawal

(iv)
for the current year.
: -- Nil --

The date of previous withdrawal or advance if

(v)
any taken for this purpose
: -- Nil --

If it is for marriage or betrothal ceremony

(C)
expenses.
: -- Nil --

(i) Whether for tha marriage or btrothal ceremony

of the subscriber's doughter/son or for any other
female relation dependent on the subscriber who : -- Nil --
has no daughter.

Whether any advance under ordinary rules has

been drawn in respect of the betrothal ceremony
(ii)
or marriage for which the present withdrawal is
: -- Nil --
sought for

Actual date celebration of the betrothal

(iii)
ceremony or marriage.
: -- Nil --

8 (i) Total of service including broken period if any :

Period of service required on the date of

(ii) application for attaining the age of :
superannuation and.
0 :0
Date of Appoinment : : The date of superanuation :

9 (a) (i) Actual cost of acquiring the house site : -- Nil --

Anticipated cost of house proposed to be built /

(ii)
re-built.
: -- Nil --

Anticipated cost of additions alteration to be

(iii)
made to the house
: -- Nil --

Actual amount required for redemption of the

(iv)
house or house site.
: -- Nil --

Total amount and date of loan taken for the

(v) purchase of house-site and the amount : -- Nil --
outstanding against that on date.
Particulars of expenses required to be incurred
(b)
on the higher education and
: -- Nil --

Amount required for meeting marriage expenses

(c) indicating the number of marriages to be : -- Nil --
celebrated.
Amount of instalment or instalment last taken. If
10 any for house building / or and purchase of house- : -- Nil --
site (State particualrs of amount dates on which
taken)
Amount if any received already from Govt. for
11 purchase of house-site or house building purpose : -- Nil --
other than from the provident account.
Recommended / Not Recommended

No.
Signature of the Applicant Desinagtion
Date: Signature of the Head of the Office or Drawing Officer

The above particulars have been verified to be correct forwarded to the

( in Triplicate )
CERTIFIED THAT
i)
The Part final withdrawal has been recommended undcer Rule G.O.Ms.No. 37, Fin.& Plg. Dt. 19-02-1975

I have satisfied myself that conditions prescribed in Rule ……………………………... referred to above have been
ii)
fulfilled

iii) The applicant has signed the under taking prescribed in rule and the same if forwarded herewith.

I have verified the progress of construction of the house and the 2nd / 3rd, 4th instalments of the withdrawal
iv)
may be paid.

I have satistied myself that the applicant as not given taken any loan / assistance under (any scheme
sponsored by the _________________ or from any other Govt. source and that the necessary note has been
v)
made regarding the verification or the requirement laid down in rule 15-A (i)(a) & C in case of complete
repayment of loan during the service of the subscriber.

vi) No part final withdrawal has been granted previously to the subscriber for the same purpose and

In addition to the part final withdrawal no temporary advance has been granted to the subscriber for the same
vii)
purpose now.
Note:- Delete the certificates applicable

(Certificate in items (ii) - (iii) and (iv) above are not necessary if the part final withdrawal is for higher
education or for betrothal ceremony or marriage purpose)

Dated the Signature

Designation

Sanction of the _____________(conveyed to the part-final withdrawal of Rs. _______________ (in

words)………………………………………………………. the amount being drawn in _________________ instalments.

No. Signature
Dated: Designation

Forwarded to 1. The Accounts Officer ____________________________

for necessary action.

Signature
Designation