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Form B

(See Rules 16 and 42)


FORM OF APPLICATION FOR TEMPORARY ADVANCES AGAINST DEPOSITS
IN GENERAL PROVIDENT FUND (KERALA)
1. Name and Account No. of the subscriber : Ajayakumar.R
CP 1405122
2. Monthly pay, dearness pay and designation : Rs.18,740
3. : Rs.63,360
Amount of advance required
(both in figures and words)
Sixty Three Thousand Three Hundred and Sixty Only

4. Purpose for which it is required : For the treatment of Subscribers Mother

5. Number of instalments of recovery proposed : 36


6. Date of complete repayment of the previous loan : Being repiad
7. Details of advances pending recovery
(1) the amounts of previous advances : Rs.25,920
(2) dates of drawal of each advance : 8/16/2010
(3) balance outstanding against each advance : Rs.4,320
7 (a).
Amount of consolidated advance items 3 and 7 (3)
and the number and amount of monthly instalments : Rs.67,680
in which the consolidated advance is proposed to be
repaid
Instalment amount Rs.1,880
Number of instalment 36
8. Name of treasury at which payment is desired : ST,Kunnathunadu
9. I hereby declare that the above statements are true and that I agree to abide by the General Provident Fund (Kerala) Rules in force. I
also promise to repay the above advance in equal monthly instalments together with interest according to rules

Place: Vazhakulam
Date : 12/14/2011 Ajayakumar.R
Head Clerk
10. Enquiry Certificate:-
1. Certified that the subscriber has no other means to raise the amount from any other sources
2. Certified that I have made enquiries about the purpose for which the loan is applied and I have satisfied
myself with genuiness of the fact stated in the application
3. Certified that the subscriber will continue in service till the complete repayment of the advance
4. Certified that the subscriber has opted the GPF(K) Rules with in the prescribed time
5. Certified that six months have elapsed from the date of drawl of the previouse advance
6. Certified that no application for advance from this subscriber is pending
Place Vazhakulam
Date: 12/14/2011 Mathai A J
Block Development Officer
Vazhakulam
Verification Report

11. Total amount at the credit of the applicant : Rs.84,637


12. Amount of advance admissible : Rs.62,280

13. Number of instalments of repayments : 36

14. Any other fact requiring consideration : Special Case No other source to raise the fund

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Mathai A J
Block Development Officer
Vazhakulam

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STATEMENT OF DEPOSIT AND WITHDRAWLS FOR THE PERIOD AFTER THE LAST CREDIT CARD
TILL THE DATE OF APPLICATION FOR ADVANCE OF GENERAL PROVIDENT FUND
Name of Subscriber Ajayakumar.R GPF Account No CP 1405122
Head Clerk Temporary Advance or NRA TA
A.Deposits
Monthly Re fund Total
Month & No of Gross Net Sub
Subscri of amount C/o Date
Year instalment Amount Amount Treasury
ption Advance Deducted

1 2 3 4 5 6 7 8 9
Mar-11 1000 0 0 1000 12/9/2011 493703 363052 ST,
Apr-11 1000 0 0 1000 12/10/2011 492968 364878 Aluva
May-11 1000 0 0 1000 12/11/2011 492387 356494 ''
Jun-11 1000 0 0 1000 12/12/2011 51715 29753 ST
Jul-11 1000 0 0 1000 12/13/2011 34407 29753 Angamali
Aug-11 1000 0 0 1000 12/14/2011 36660 29753 ''
Sep-11 1000 0 0 1000 12/15/2011 33252 28498 ''
Oct-11 1000 0 0 1000 12/16/2011 33252 28498 ''
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Dec-99 0 0 0 0 12/30/1899 0 0 0
Total 8000 0 0 8000 0 0 0 0

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B.Details of DA credited GPF(Based on which withdrawl is allowed)Since last credit card

No & Date of GO As Period to Amount Date of Gross Net Name of


Sl per which the DA which the credited encash Amount Amount of Treasury
No arrears was credited arrears to GPF ment of of the Bill the Bill
to GPF related Rs. the Bill
1 2 3 4 5 6 7 8
1 0 0 Nil 0 0 0 0
Total 0

C.DETAILS OF WITHDRAWLS MADE AFTER THE LAST CREDIT CARD

No and date of Date of Nature of Purpose Remarks


Sl Sanction with Amount Name of Advance
No Drawl Rs. Treasury TA/NRA
1 2 3 4 5 6 7 8
1 Nil
2
0
If there is no withdrawl since the last credit card that fact should be specifically stated in the performa
D.ABSTRACT
1 Total amount at credit as per last credit card for the year 2010-11 111009
2 Total amount at credited to PF A/c after last credit card(Total A+B above) 8000
3 Total Credit( Items 1+2 above) 119009
4 Amount not allowed to withdrawn included in credit card (DA/arrears) 34372
5 Total 84637
6 Deduct amount of advance drawn after the issue of last credit card (C above 0
7 Net balance at credit of the subscriber on the date of application(5-6) 84637
8 Balance of previouse advance 4320
9 Amount of advance admissible 84637 X 3- 4320 62398
4
10 Amount required 63360

Certified that the particulars furnished above have been verified with reference to pay abstract
acquittance roll PF.Pass Book and other connected records and found correct

Vazhakulam Mathai A J
12/14/2011 Block Development Officer
Vazhakulam

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CALCULATION STATEMENT OF GENERAL PROVIDENT FUND
Name Ajayakumar.R A/C No CP 1405122 Date as on 40891

1 Balance of Previous advance : 36 30 = 6x 720 = 4320

2 Amount admissible : 84637 x 3 4320


4
62398

3 Amount required : 63360

Consolidate amount of Rs. 67680 ( 4320 63360 ) will be recovered in 36


Instalments @ Rs 1880 \PM

Mathai A J
Block Development Officer
Vazhakulam

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FORM C
(See Rules 16 and 41)
FORM OF SANCTION FOR TEMPORARY ADVANCE FROM GENERAL PROVIDENT FUND(KERALA)

A temporary advance from the General Provident Fund(Kerala) as particularised below is sanctioned
by the under signed under the rules regulating that fund.

No. A.283/11 K.Dis Dated. 12/14/2011

1 Subscribers Name Ajayakumar.R


2 Subscribers Designation Head Clerk
3 Subscribers Pay and Dearness Pay Rs. 18740
4 Subscribers Provident Fund Account No. CP 1405122
(a) No and Date of granting previous temporary Adv. No.A.750/10 of APO,RAIC
Aluva(Converted as NRA)

(b) Amount of previous temporary advance Rs. 25920


(c) Date of the previous temporary advance 8/16/2010
5 Amount of advance Rs. 63360
Rs. Sixty Three Thousand Three
Hundred and Sixty Only

6 Object of advance For the treatment of Subscribers Mother

7 Rule or rules under which the advance is sanctioned 16(1) (d).GPF (K) Rules
8 Balance at credit of the subscriber on this date (As
verified from account last render by the Head of Office Rs. 84637
9 Balance of previous advance, If any outstanding
against the subscriber (Principal and interest Rs. 4320
shown separately)
10 Date of repayment of previous advance if any Being repaid
11 Special reason for granting the advance Special Case No other source to raise the fund
12 Amount of consolidated advance Item 5 and 9 and Rs. 67680 4320 63360 )
the No. of installments in which the consolidated to be recoverd in
advance to be recovered. 36 Installments @ Rs. 1880
13 Amount of each Installment Rs. 1880 /PM
14 Date of Birth 4/6/1966
15 Date of retirement 3/31/2022

Mathai A J
Block Development Officer
Vazhakulam
Copy to
1 The Accountant General (Kerala)

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2 The Sub Treasury Officer, ST,Kunnathunadu
3 The Bill,
4 Ajayakumar.R Head Clerk

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Below Rs 63361 Rs. Sixty Three Thousand Three Hundred and Sixty One Only
Form D
(See Rule 16,18 & 42)
BILL FOR DRAWING FINAL/ADVANCE PAYMENT FROM THE G P F ACCOUNT

Name of Treasury ST,Kunnathunadu 223322


Computer Seqence No../ Token No. Date: 12/14/2011

Scroll No……………………………………………………. Voucher No........................................of I/II LOP

DDO Code (Dept)


630 (DDO)
731 In case of SDO SDO code 1207630
Mathai A J
Name & Designation of drawing officer
Block Development Officer

Name of Office Block Development Office,Vazhakulam

Bill No………………………………………….For the month 12/2011 Adjustable by…………………………………………

PF Head of Account

Head of Account 2515 00 001 49 01 Sala Plan(P)/Non-Plan(N) Voted(V)/Charged(C)

Sl No Name of subscriber & Monthly pay GPF Account No Number & Date of sanction Order
1 Ajayakumar.R No. A.283/11 Dt 12/14/2011
Head Clerk CP 1405122 of Block Development Officer

Pay Rs. 18,740 Block Development


Office,Vazhakulam

Grand Total

Received Rs. 63360 (Rs. Sixty Three Thousand Three Hundred and Sixty Only

Place Vazhakulam Mathai A J


Date 12/14/2011 Block Development Officer
Block Development Office,Vazhakulam
SPACE FOR ENDORSEMENT

Please pay the amount to Sri/Smt ................................................................................................................................


Whose signature is attested below
Contents received

Mathai A J
Signature of messenger Block Development Officer Signature of messe

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Block Development Office,Vazhakulam
FOR TREASURY USE ONLY
Pay………………………..(Rupees………………………………..………………………………..………...………………………onl
in cash/cheque, Rs……………………………(Rupees……………………………………………………...………………………onl
by RBR and Rs………………………………..(Rupees……………………………………………….………………….……only by T

POC No……………………………………………...…………..Date………………/…………./……………….

Accountant

Received Pay Order Cheque Pay Order cheque issued by

Signature of the Recipient Accountant

CERTIFICATE
1. Certified I have satisfied myself that all sums included in bills in Form D drawn 1, 3 months previous to this date in
favour of Messers……………………………………………………Account Nos……………………………………………..
With the exception of those detailed below ( of which the total has been refunded by deduction from this bill) has been
disbursded to the proper persons and that their acquitances have been taken and filed in my office with receipt stamp
duly cancelled for every payment as per stamp act.

2. Certified that I have satisfied myself that the amount withdrawn previously on the same account has been utilized
by the subscriber on the date of the withdrwal covers the sum in the relevant premium receipt/receipts has/have duly
enfaced by me.

Place: Vazhakulam Mathai A J


Date 12/14/2011 Block Development Officer
Block Development Office,Vazhakulam

Note: Separate bill should be prepaed for each index prefix of GPF Accounts.
FOR THE OFFICE USE ONLY

Admitted Rs……………………………………………..

Objected Rs……………………………………………..

Reason for objection……………………………………

Auditor SO/AAO Branch Officer

Commonly used provident fund head of accounts

Provident Fund Type Decode Head of Account Provident Fund Tyep Decode H/Ac.
8009-01-
KPEC & PPSPF 119 8009-01-101-90 Panchayath Emp. PF 124 101-93
8009-60-
KASEPF 120 8009-01-101-98 Contri.Prov.Pension Fund 126 102-00
8009-01-
KPCSPF 121 8009-01-101-97 KASRSEPF 127 101-92
8009-01-
KPCNSPF 122 8009-01-101-96 Continency Emp.PF 128 101-98
8009-01-
123 8009-01-101-95 GPF 701 101-99
INSTRUCTIONS

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1. All sanction orders, for advances, should specify the name and designation of the officer who actually sanctioned
the advavance/withdrawal.
2. The sanction orders must be authorized/signed by the drawing and disbursing officer of the office of the sanction-
ing authority whose name and designation should invariably be given below the signature and in case where the san-
ction order could not be signed by the Gazetted Officer in charge of the wing whose name and designation should be
given below the signature.
3. The office seal of the sanctioing authority's office must be affixed in the sanction orders.
4. AnnexureABCD should be attached in the bill along with the sanction order in case advances from G.P.F.

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One Only

P F ACCOUNT

2233222
12/14/2011

.............of I/II LOP

1207630731

………………………………………….

Voted(V)/Charged(C)

anction Order Amount


12/14/2011
pment Officer
63360
opment
akulam

63360

Only )

.........................................

Signature of messenger

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...………………………only)
...………………………only)
……………….……only by TC

Treasury Officer

evious to this date in


……………………..
m this bill) has been
e with receipt stamp

t has been utilized


eipts has/have duly

ccounts.

H/Ac.
8009-01-
101-93
8009-60-
102-00
8009-01-
101-92
8009-01-
101-98
8009-01-
101-99

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ctually sanctioned

ce of the sanction-
ase where the san-
signation should be

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Form D
( See Rule 16,18,42 of GPF(K)Rules )

Form of Bill for payment of Provident Fund Mony


ADJUSTABLE BY
Voucher No……………………………….

Date 12/14/2011

Payment/Advance

Bill for with drawing Final/Temporary Advance /Other from the KASEPF/
General Provident Fund (Kerala) of Smt/Sri. Ajayakumar.R Head Clerk
of the Block Development Office,Vazhakulam for the month 12/2011
No and date
Final Payment/
Name of Subscriber and PF Account of sanction/
No Advance/other Acquittance
monthly pay No Letter of
withdrawls
authority
1 2 3 4 5 6
1 Ajayakumar.R A.283/11 63360
Head Clerk CP 1405122 12/14/2011
Rs.18,740
Block
Development
Officer
Vazhakulam

Total 63360
Net amount required for payment
In words Rs. Sixty Three Thousand Three Hundred and Sixty Only

Space for classification

Pay Rs.

Station Vazhakulam Contents Received


Date 40891 Please pay the amount to

Treasury Officer
Mathai A J
Examined and entered Block Development Officer
Vazhakulam
Treasury Accountant

1.Certified that I have satisfied myself that all sums included in bills in form drawn 1 month/
2months/3months previous to this date in favour of Massers…………………………………………….
Account Nos……………………….with the exception of these detailed below(of which the total has
been refunded by deduction from this bill) have been disbursed to the proper persons and their
acquittance have been take and filed in my Office with receipt stamp duly cancelled for every
payment in excess of Rs.20/-

II.Certified that the balance at my credit/at the credit of the subscriber or the purpose for which
it was intended and that the bill certified also that amount asked for in this bill is required to
meet the early premium due on……………………………………………………………………
respect of Policy No…………………with the LIC and that the Policy in quistion has been assigned
to the Governor and is the custody of the accounts officer………………………………………
or the details of the policy proposed to be taken have been communicated to and accepted by the
account Officer in his letter No……………….Date…………………..

Certified also that the number of policies financed from the KASEPF/GPF(Kerala)does exceeds
four as these were accepted prior to the Commancement of KASEPF/GPF(Kerala)Rules

Certified further that I have satisfied myself that the amount withdrawn previosly on the same
account has been utilised by the subscriber on the data of the withdrawl covers tha sum drawn
in the relevent premium receipts have been duly enfaced me

Mathai A J
Block Development Officer
Vazhakulam
Given details if more than one policy has to be cited

For the use of Audit Officer

Admitted………………………………………………………………..

Objected Rs, ……………………………………………………………..


Auditor
F O R M NO.J.
[See Rule 28 (c)]
Form of Application for conversion of an advance into part final withdrawal
1 Name of the Subscriber Ajayakumar.R
Designation and Head Clerk
2 Office to which attached Block Development Office,Vazhakulam
Vazhakulam
3 Pay Rs.18,740
Name of the Provident Fund and General Provident Fund(Kerala)
4
Account Number CP 1405122
Balance at credit on the date of
5 application (amount actually Rs.84,637
subscribed by him along with
interest due thereon
Balance outstanding to be
6 converted into a part final Rs.4,320
withdrawal
Purpose for which the advance
7a) Treatment of Mother
taken
b) Date of payment of advance 8/16/2010
c) Amount of advance sanctioned Rs.25,920
No.A.750/10 of APO,RAIC Aluva(Converted as
8 Particulars of communication under NRA)
which the advance was sanctioned
Whether any advance of part final
withdrawal has been drawn
9 previously for the purpose Yes
mentioned above. If so, particulars
thereof
Total service including broken
10 a) periods, if any, on the date of this 21 Year(s), 5 Month(s),
application
Period of service left on the date of
b) application for attaining the age of 10 Year(s), 3 Month(s),
superannuation
c) Date of superannuation 3/31/2022

Sd
Place: Vazhakulam Ajayakumar.R
Date : 12/14/2011 Head Clerk
Block Development Office,Vazhakulam

The above particulars have been verified and found correct.

Mathai A J
Block Development Officer
Block Development Office,Vazhakulam

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FORM B - 1
[See Rules 28 (A) and 40]
APPLICATION FOR NON-REFUNDABLE WITHDRAWAL
FROM THE GENERAL PROVIDENT FUND (KERALA)
1 Name and Designation of the Subscriber Ajayakumar.R
Head Clerk
2 Pay and Dearness Pay Rs.18,740
3 a) Provident Fund Account Number (the guide letters
allotted to the Department, viz., Medl. for Medical, Edn.
for Education, etc., should also be furnished)
CP 1405122
b) Reference number of Annual Statement indicating
Section Number, Unit Number, Volume Number and Page
Number.
4 Whether the Subscriber had opted for the GPF(Kerala) Rules Yes
within the prescribed time limit.
5 Date of retirement on superannuation 3/31/2022
6 Total service (in years) under Government as on this 21 Year(s), 5 Month(s),
date
7 Object of the withdrawal
a. If the withdrawal is required for meeting the
expenditure in connection with the:-
i) Higher Education of any child or dependent of the
subscriber
ii) of a son or daughter or any other female relative
dependent of the subscriber
iii) Illness of the subscriber or any person actually
dependent on him
iv) a. Acquisition of land or
acquisition of house site
b. Acquisition of house or
acquisition of ready-built flat
v) a. Construction of a house
b. Addition, alteration or
reconstruction of house
c. Maintenance/repair or upkeep
of house
vi) Purchase of car, motor
cycle/scooter
vii) a. Meeting expenses in
connection with marriage
b. Whether the withdrawal is
required for repayment of
loan taken for any of the
above purpose
8 Amount of the withdrawal proposed (both in figures Rs.63,360
and words)
Sixty Three Thousand Three Hundred and Sixty Only

9 Name of the Treasury at which payment is desired ST,Chavakkadu

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10 a. Whether any Non-Refundable withdrawal was made
by him from the Fund previously for the same or different
object and, if so, furnish the details thereof.
b. If any withdrawal was made as mentioned above,
state whether he had submitted the Utilization Certificate
in respect of that withdrawal to the appropriate authority
within the prescribed time limit. If the Certificate was not
submitted within the said period, furnish the reasons
therefore

DECLARATION

I, Ajayakumar.R Head Clerk


Statements furnished by me are true and that I agree to abide by the General Provident Fund (Kerala)
Rules as amended from time to time.

Ajayakumar.R
Head Clerk
Block Development Office,Vazhakulam
Vazhakulam

(To be filled in by the Head of Office/Department)

I recommend for sanction the withdrawal of Rs 63360


Rs. Sixty Three Thousand Three Hundred and Sixty Only
by the subscriber

Mathai A J
Block Development Officer
Block Development Office,Vazhakulam

CERTIFICATE

1. It is certified that I have verified the particulars furnished by the Subscriber against columns 2, 3, 4,
5, 6 and 11 with reference to the relevant records in my office and that they are found to be correct.
2. It is also certified that I have caused enquiries to be made about the statement contained in the
application regarding the object of the proposed withdrawal and that I am satisfied that it is bona fide.

Mathai A J
Block Development Officer
Block Development Office,Vazhakulam

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