B™.Éç³.Éç³.i.Á.ÔéQ ¯ðþ™.

41
DIR. OF INS. NO. 41

B™É«æþÉ糧óþԏý É糿æý€èþÓ ÁÐèþ’ yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ
GOVERNMENT OF A.P. DIRECTORATE OF INSURANCE

ɴ뙡Äèÿ ÁÐèþ’ yìþ³ç “Åsìü yðþƔ ÿð MæüÆt ÿæ  MéÆéÅËÄèÿÐèþ. ..............
OFFICE OF THE REGIONAL DEPUTY DIRECTOR OF INSURANCE ............
º}ýÐèþ MöÆæÿN §æþÆæÿRêçܐ¢

Application for Loan
(çܒ^èþ¯èþË MöÆæÿN Éí³µ ^èþ’yæþyæþ)
1.

^èþ™§é §éÆæÿ° õ³Ææÿ €èþ™Éyìþ õ³Ææÿ çßø§é

(For instructions, Please see overleaf)

Name, father's name and the designation of the subscriber

2.

________________________________

A€èþyæþ ç³°^óþçܐ¢¯èþ² MéÆéÅËÄèÿÐèþ õ³Ææÿ
The name of the office where he is employed

3.

________________________________

^èþ™§é §éÆæÿ ¯ðþ™ºÆæÿ ÌôýMæü ´ëËïÜ ¯ðþ™ºÆæÿ
Subscriber No. or Policy No.

4.

________________________________

§æþÆæÿRêçܐ¢Ìø Møǯèþ Ææÿ’´ëÄèÿË Ððþ€èþ¢Ðèþ
The amount of the loan applied for

5.

________________________________

º}ýÐèþ §óþ°MöÆæÿN AÐèþÜç ÆæÿÐèþ (Ððþ¯èþMæü VæüË Üç ’^èþ¯èþ˯èþ
§æþ–íÙtÌø Äèÿ™^èþMö° §æþÆæÿRêçܐ¢Ìø ÌôýMæü ©°€ø
糙糑 ÌôýQÌø ÑÐèþÆæÿÐèþË¯èþ €ñþːç³ÐèþÌñý¯èþ).
The object or objects for which the loan
is required (full particulars may please begiven
in the covering letter or application keeping in
view the instructions printed overleaf)

6.

________________________________

º}ýÐèþ ÇW H°² ÐéÆÿ§éËÌø ^ðþÍϙ^èþ §æþË^èþMö¯é²Ææÿ
The number of instalments in which the loan is
proposed to be repaid. (Not exceeding 48
according to Rules 46)

7.

^èþ™§é §éÆæÿ ´÷™§óþ Ððþ€èþ¢Ðèþ ¯ðþËçÜÇ i€èþÐèþ

8.

Ðóþ€èþ¯èþÐèþ ¯èþ™yìþ €èþWY™ç³‘ː

________________________________

Total monthly emoluments drawn by the subscriber

________________________________

Deductions from pay

(G)

B.Éç³.Éç³.i.Á. ÔéQ Éï³ÑÄèÿÐèþ

(¼)

B™.Éç³.Éç³.i.Á.ÔéQ º}ýÐèþ ÐéÆÿ§é

(íÜ)

H§æþÆÿ¯é C€èþÆæÿ çÜçßMéÆæÿ çܙZÐèþ ÌôýMæü çܙZÐèþË ÐéÆÿ§é Ððþ€èþ¢™

________________________________

A.P.G.L.I. Dept. Premum

________________________________

A.P.L.I.D. Loan instalment

________________________________

Instalments of any other Co-operative Society a Societies

________________________________

(yìþ) »êřN º}ýÐèþ
Bank Loans

(C)

________________________________

É糿æý€èþÓÐèþ Ðèþ™lÆæÿ ^óþíܯèþ Ððþ’sêÆæÿ MéÆæÿ º}ýÐèþ ÌôýMæü Væü–çß °ÆéÃ}ýÐèþË
Motor Car Loan or House Building Loan sanctioned by Government

________________________________

(GŽ·) B§éÄèÿç³‘ 糯èþ²
Income Tax

(h)

________________________________

HÐèþÆÿ¯é C€èþÆæÿ €èþWY™ç³‘ː
Any other deductions

________________________________

Ððþ€èþ¢Ðèþ
Total

9.

The name of the Treasury or branch of the State Bank
where the payment of loan is desired.

10.

________________________________

º}ýÐèþ ^ðþÍϙ^èþ MøÆæÿ ÉsóüfÈ ÌôýMæü õÜtr »êřN É»ê™_ õ³Ææÿ
________________________________

_Ææÿ¯éÐèþ’
Address

________________________________

ò³”¯èþ €ñþÍí³¯èþ ÑÐèþÆæÿÐèþË, f€èþ ç³Ææÿ^èþºyìþ¯èþ §æþÆæÿRêçܐ¢Ìø €ñþÍí³¯èþ ÑçÙÄèÿÐèþË çÜÇÄðÿ”¯èþÐèþ°Äèÿ ò³” €ñþÍí³¯èþ AÐèþçÜÆæÿÐèþ ÌôýMæü A¯èþÐèþçÜÆæÿÐèþË
°Ñ€èþ¢Ðèþ Ðèþ’É€èþÐóþ ò³”MæüÐèþ¯èþ QÆæÿa ^óþÄèÿVæü˯èþ°Äèÿ C™§æþ Ðèþ’ËÐèþ¯èþ Éç³Mæüsìü™^èþ^èþ¯é²¯èþ. ÔéQ °ÄèÿÐèþ’Ðèþã ¯èþ¯èþçÜǙ_ B™É«æþÉ糧óþԏý É糿æý€èþÓ
ÁÐèþ’ ÔéQ MéÆæÿŧæþÇØMìü °Ææÿ~Æÿ™^èþ 糧æþ®€èþË¯èþ, Ðóþ€èþ¯èþÐèþ ¯èþ™_ º}ýÐèþ, Ðèþyìþz €èþXY™ç³‘˯èþ ^óþÄèÿ E€èþ¢ÆæÿÓː gêÈ ^óþÄèÿrN C™§æþ Ðèþ’ËÐèþVé
ÐéÇMìü A¬MéÆæÿÐèþ C^èþa^èþ¯é²¯èþ.
I hereby declare that the particulars stated above as well as those mentioned in the covering application are
correct and that I shall spend the amount received only on the object or objects, mentioned above. I hereby
authorise the Director Directarate of Insurance Department Government of Andhra Pradesh to pass orders to effect
recoveries of Loan and interest from my salary in the manner as may be prescribed by him in accordance with the
rules of the Department.

€ôþ¨ :

§æþÆæÿRêçܐ¢ §éÆæÿ çܙ€èþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ ÐèþÉ§æþ

Date ....... 197

Signature of Thumb Impression of the applicant

ò³” §æþÆæÿRêçܐ¢Ìø €ñþÍí³¯èþ ÑÐèþÆæÿÐèþË ¯éN €ñþÍíܯèþ™€èþ ÐóþÆæÿN ¯óþ¯èþ ÑÔèýÓíܙ^èþ¯èþ™€èþ ÐèþÆæÿN Äèÿ§éÆæÿ¦ÐèþË°Äèÿ, ò³” çܙ€èþMæüÐèþ ÌôýMæü »ör¯èþ
ÉÐóþÍ ÐèþÉ§æþ ...................................................... VéÇ §æþ°Äèÿ C™§æþ Ðèþ’ËÐèþVé «æþ–ÒMæüǙ^èþyæþÐðþ”¯èþ¨. BÄèÿ¯èþ B™.Éç³.Éç³.i.Á.
ÔéQ ¯èþ™yìþ Ææÿ’. .................................... º}ýÐèþ ¡çܐMö° Äèÿ¯é²Ææÿ. C™§æþË C™Mæü¯èþ’ Ææÿ’. ....................................
ː »êMîü Äèÿ¯é²Ææÿ.
It is hereby certified that the particulars stated in the above application are correct to the best of my knowledge and belief and that the above signature or thumb/impression is of Shri ...........................................................
He ad obtained a loan of Rs. ........................... from A.P.G.I. Dept. out of which Rs. ..................... are still outstanding.

«æþ–ÒMæüǙ^èþ Vóühsðütyþ A¬MéÇ çܙ€èþMæüÐèþ
Signature of the
certifying Gazetted Officer ___________________

€ôþ¨:

«æþ–ÒMæüǙ^èþ A¬MéÇ õ³Ææÿ

Date ... 197

Name of the certifying Officer _________________

MéÆéÅËÄèÿÐèþ ÐèþÉ§æþ

çßø§é

Office Seal

Designation _______________________________

VæüÐèþ°Mæü:& §æþÆæÿRêçܐ¢ §éÆæÿ C¨ÐèþÆæÿMóü ÁÐèþ’ ÔéQ ¯èþ™yìþ º}ýÐèþ ¡çܐN¯èþ² ÄðÿyæþË ò³” «æþ–Ðèþ ç³É€èþÐèþò³” §æþÆæÿRêçܐ¢ §éÆæÿ°, AÐèþÅÐèþí߀èþ E¯èþ²€ø§øÅW
çܙ€èþMæüÐèþ ^óþÄèÿÐèþÌñý¯èþ.
Note:-

In case the applicant has already obtained loan from Insurance the above certificate should be signed by
the applicant's immediate superior.

糨 ò³”çÜË Ýët™ç³‘

B™.Éç³.Éç³.Á.Mé.{îþ.¯ðþ™.40

Stamp 20 P.

DIR. OF INS. F. NO.40

ÆæÿÖ§æþ
RECEIPT

VæüÐèþ°Mæü:& Ððþ€èþ¢Ðèþ Ææÿ’. 20 ËN ѐ™_¯èþ GyæþË Ýët™ç³‘ A™sìü™^èþÐèþÌñý¯èþ.
Note:- If the amount exceeds Rs. 20, this receipt should be duly stamped.

×/×Ðèþ ...................................................................... VéÇ ÁÐèþ’ / É´ëÑyðþ™r 緙yæþ/º}ýÐèþ/
»ø¯èþçܐ Ððþ€èþ¢Ðèþ¯èþN çܙº™¨™_¯èþ ^èþ™§é§éÆæÿ ¯ðþ™ºÆæÿ ................................... ÆæÿÖ§æþ .................................. AÆÿ¯èþ
¯ó þ ¯è þ  C™§æ þ Ðè þ ’ËÐè þ Vé B™É«æ þ Éç ³ §ó þ ԏ ý Éç ³ ¿æ ý €è þ Ó ÁÐè þ ’ MéÆéÅËÄè ÿ Ðè þ , ò ß ” § æ þ Æé»ê§æ þ  ¯è þ ™yì þ Ææ ÿ ’´ëÄè ÿ Ë (A™Mð ü ËÌø)
................................... (A„æþÆæÿÐèþËÌø) .................................................................. çÜÓÄèÿÐèþVé ×/
×Ðè þ 

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

§éÓÆé

................................................................. €ôþ© VæüË .................................... ¯ðþ™ºÆæÿ ^ðþNP & »êřN
Éyé緑t §éÓÆé Ðèþsìüt¯èþrÏ €ñþÍÄèÿç³Ææÿ^èþ^èþ¯é²¯èþ.
Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of
Sri/Smt. .............................................................................. Subscriber No. ....................................................
I .............................................................................. hereby knowledge receipt of Rs. (in figures
......................................... ) (in words ........................................................................................................ ) From
the Directorate of Insurance, Hyderabad per self, Sri/Smt. ..............................................................................
Attorney/Bearer * per Cheque / B.D. No. ........................................ Dated ....................................... 19

¡çܐN¯èþ² ÐéÇ çܙ€èþMæüÐèþ
Signature of receipient

.

´ëËïܧéÆæÿ & MðüÏÆÿÐèþ§éÆæÿ ÄðÿMæüP çܙ€èþMæüÐèþ Ìôý§é »ör¯èþÉÐóþÍ ÐèþÉ§æþ
Signature of thumb-Impression of the Policy holder/
Claiment.

[P.T.O.

¯é çÜÐèþ„æþÐèþÌø çܙ€èþMæüÐèþ ^óþíܯèþ ò³” çܙ€èþMæüÐèþ & ÐóþÍ ÐèþÉ§æþ

____________________________ ÐéÇ É«æþÒMæüÆæÿ}ýÐèþ

×/×Ðèþ ......................................................

糑ÆæÿçÜPǙ^èþMö° ò³” ^ðþNP¯èþ çÜÓÄèÿÐèþVé A™§æþgôýÄèÿyæþÐðþ”¯èþ¨.

¯óþ¯èþ C™§æþ Ðèþ’ËÐèþVé «æþ–Ðèþç³Ææÿ^èþ^èþ¯é²¯èþ.

______________________________________

I hereby certify that the above signature/thumb
impression is of Sri/Smt. ______________________

On the strength of certification of

_______________________________________________
the above cheques reserved personally .

who has signed in my presence.

Væühsðüyæþ A¬MéÇ õ³Ææÿ
1.

Name of the Gazetted Officer______________
___________________________________
___________________________________

çßø§é
2.

çܒç³Ç™sðü™yðþ™r

Designation __________________________

Superintendent

çÜàÄèÿ çܙ^éËNyæþ, ÁÐèþ’
Asst. Director of Insurance

«æþ–ÒMæüǙ_¯èþ €ôþ¨
3.

Date of Attestation ______________________

MéÆéÅËÄèÿç³‘ ÐèþÉ§æþ
OFFICE SEAL

VæüÐèþÝë¢
Clerk

«æþ–ÒMæüǙ_¯èþ A¬MéÇ çܙ€èþMæüÐèþ
Signature of the Certifying
Gazetted Officer

VæüÐèþ°Mæü:& B™É«æþÉ糧óþԏý çÜÈÓçܐÌø Äèÿ¯èþ² Væühsðüyæþ A¬MéÇ^óþ Vé°, A¿æýÅÇ® Æé‹Ðèþ Ððþːç³Ë °ÐèþíÜçܐ¢¯èþ²rÏÆÿ¯èþ^ø ÐóþhÉõÜtr^óþ ÆæÿÖ§æþ «æþ–
Ðèþç³Ææÿ^èþÐèþÌñý¯èþ.
Note:-

The receipt should be certified by a Gazetted Officer of Andhra Pradesh Government in Service or by a
Magistrate if the applicant is residing outside the State.

Sign up to vote on this title
UsefulNot useful