G-376-A

SOUTHERN RAILWAY
APPLICATION FOR FINAL WITHDRAWAL FROM PROVIDENT FUND FOR
MEDICAL EXPENSES IN TERMS OF PARA 1323(5)-R.I
***
1
Name of the employee (in Block letters)
2
Staff No.
3
P.F.No.
4
Designation & Station
5
Department
6
Date of birth
7
Date of appointment
8
Date of superannuation
9
Rate of pay
10 Amount of compulsory P.F. Deposit as per
last PF slip issued
11
Amount applied for
12 Name, age & relationship of person for
whose sickness withdrawal is applied for
13 Nature of sickness
14 Whether the person mentioned against item12 is actually dependent on him
I solemnly declare that the amount applied for is solely for the purpose of
meeting expenses in connection with the illness of the person mentioned against
item-12 and will be actually utilised for the purpose only. I will furnish a
certificate to the sanctioning authority within one month after the course of
treatment is over, to the effect the amount withdrawn has actually been utilised for
the purpose for which it was intended and will refund any unspent amount. In the
event of my not furnishing the certificate or if the amount withdrawn is utilised for
a purpose other then that for which sanction was given, I will deposit forthwith the
entire amount withdrawn from the PF together with interest thereon in one lump
sum. The sum of Rstaken by me onfor the medical expenses of
my...has been fully utilised for the purpose for which it was taken.
Station:
Date :
Signature of the employee
All the particulars including signature of the employee has been verified and found
correct.
Forwarded in duplicate to Sr.DPO/MAS for necessary action.
Station:
Date :
Signature of the Immediate Supervisor.

No.

Office of
Date :

Sanction Rs./- (Rupees.only) or

50% of his own subscription with interest at credit which ever is less. Conditions
specified in para-1323(5) R.I are satisfied.
Forwarded to.for arranging payment in the presence of.
Signature of Officer & Designation
Passed for

Rs.R

Less Deduction

Rs.

Net amount payable

Rs.
Rupees

Date
for Sr.DFM (PF)
Received the sum of RRs.
as detailed above.

Rupees

Date :
Payees Signature
Witness:
Payment to has been made to and received by the payee
identified by me and signed by him in my presence.
Paid by me on
Signature

Designation :
Station
Pay Clerk