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1. Name 2. Designation 3. Z.P.P.F A/c No 4. Place of Working 5. Salary A/c No Bank Name B r an c h 6. Balance as per P.F Balance Sheet for the Year : : : : : : : :
9. Other Adjustments (Specify Such As D .A., PRC arrears etc.,) : 10. Tota l Balance (6+7+8+9) 11. Pending Advance if any (-) 12. Net Balance Availab le 13. Loan Amoun t applied/requ ired : : : :
14. Whether its within the permissi ble Provisions or not : 15. If not specify reasons for special Consideration : Signature & Seal of D DO