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.