प्रधान निदेशक लेखापरीक्षा(के न्‍द्रीय) का कार्यालय

OFFICE OF THE PRINCIPAL DIRECTOR OF AUDIT (CENTRAL)

LEKHA PARIKSHA BHAVAN, 361 ANNA SALAI, CHENNAI – 600 018

APPLICATION FOR PART / FINAL FROM GENERAL PROVIDENT FUND

FOR THE MONTH OF ___________
MODE OF PAYMENT: DD / CHEQUE / CASH / ECS

1. अभिदाता का नाम/ Name of the Subscriber

2. सा.भ.नि. लेखा संख्‍या/ G.P.F. Account Number
3. पदनाम एवं अनुभाग/ पार्टी नाम/सं.
Designation & Section / Party Name / No.
4. वेतन/ग्रेड वेतन Pay / Grade Pay
5. सेवानिवृत्ति की तिथि / Date of Superannuation
6. सेवा में कार्यग्रहण की तिथि/ Date of Joining Service
7. Balance at Credit of the Subscriber on the date of application
as below:
i) C.B. as per statements for the year Rs.
ii) Subscription From To Rs.
iii) Refund of Advance From To Rs.
iv) Withdrawals From To Rs.
v) Net Balance at Credit as on date Rs.
8. आवयश्‍क आहरण की राशि / Amount of Withdrawal required Rs.
9. a) उद्देश्य जिसके लिए आहरण आवश्यक है
Purpose for which the withdrawal is required
b) नियम जिसके तहत अनुरोध आवरित है
Rule under which the request is covered
c) यदि आंशिक अंतिम आहरण गृह निर्माण हेतु मांगे गए हो तो
निमनलिखित सूचना दी जा सकती है
If PFW is sought for House Building etc., the following
information may be given
i) प्लॉट का स्थान और माप /Location & Measurement of
Plot
ii) Whether the Plot is fresh hold or on lease
iii) Plan for construction
iv) If the Flat or Plot being purchased is from M.B.
Society, the name of the society, the location and
 measurement etc.,
v) Cost of construction Rs.
vi) If the purchase of Flat is from DDA or any Housing
Board etc., the Location, Dimension may be given
vii) Amount of HBA Sanctioned Rs.
viii) Amount of any other assistance received in this Rs.
regard from any other Government source
10 क्या पहले इसी उद्देश्य के लिए कोई आहरण लिया गया था, यदि हां, तो राशि
वर्ष बताएं
Whether any withdrawal was taken for the same purpose
earlier, if so indicate the amount year
11 भविष्य निधि का रखरखाव करने वाले लेखा अधिकारी का नाम PAO / IAD, Chennai - 18
Name of the Accounts Officer maintaining the Provident Fund
"प्रमाणित किया जाता है कि ___________ महीने के दौरान मेरे जीपीएफ खाता संख्या ___________ से
भाग/अंतिम निकासी के रूप में मुझे स्वीकृ त रु.__________ (रुपये ______________________________
_______________________) की राशि का उपयोग उस उद्देश्य के लिए किया गया था जिसके लिए इसे निकाला
गया था"
“Certified that the sum of Rs.______________ (Rupees
______________________________ ____________________________only) sanctioned to
me as Part / Final withdrawal from my GPF Account No. ___________during the month of
_______________ was utilized for the purpose for which it was drawn”

दिनांक/ Date: आवेदक का हस्‍ताक्षर

SIGNATURE OF THE APPLICANT