.

12
FORM No. 12

Q yMtr, B, .
DIRECTORATE OF INSURANCE :: ANDHRA PRADESH :: HYDERABAD

Q ys yMt M ____________________________________________
OFFICE OF REGIONAL DEPUTY DIRECTOR OF INSURANCE _________________________

. 1
FORM NO.1
Q yMtr M, y Mst R
( ^ ^)
APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE ::
HYDERABAD
(To be filled by the subscriber)

1.

2.

3.

^ , A y,

Subscriber's name and name of his

father and designation

^ _ k ^
M , h

Name of the office and the District

where the subscriber was last in service

^ , , s
s A yry
yr, ht .
Number of policy or policies and their
respective amounts or register number
of the subscriber if he was a member
of theProvident Fund.

4.

^s

Date of Maturity of the Policy

5.

6.

G)

a)

Date of termination of service

^ _

b)

Month of last deduction of premium

D 55/58
MNy M
^?
Is the amount being claimed
before the completion of age 55/58

7.

D ^ Mst
B sf
ts M B
ts M B Cy _

Name of the Andhra Pradesh

Government Treasury or the Branch
of the State bank of Hyderabad or
State Bank of India from which
payment is desired.

8.

^ _ (5) H ^
M :
Office in which the subscriber has
worked during the last (5) years

9.

R _
Full address of the Applicant

10) G)

. ..................................... H..h.G.I. y } .
D M V, . .............................. ^^ . D
yz y ^M^a.
I have obtained A.P.G.L.I. Loan of Rs. ____________________ , out of which
I have to pay Rs. ______________________ which may be recovered alongwith
interest from my policy amount.

H AM r ^ fW MV , Ast AM W ^^N
y , Ast ^ y WY^MN g CV
Ms^^.
I do hereby declare that if in future it is found that any excess payment was made to me in advertantly,
I shall be held responsible to repay such excess amount and given my consent for deduction of the same
from my pension instalments.

: _____________

^ M

Date: _____________

Signature of Subscriber

^ M/ ^r __________________________________________________
(y ) __________________________ M^y.
This is to certify that the above signature thumb impression is of ____________________________________
S/o. _______________________________________

:
Date:

M Vhsy AM M:
Signature of the Certifying Gazetted Officer

M
OFFICE SEAL

AM :
Name of the Officer :

:
Designation:

 t
REVENUE
STAMP 1 RUPEE

RECEIPT

VM: M . 500&00 N _r D N t AM^.

Note: If the amount exceeds Rs. 500/- this receipt should be duly stamped.

.
V ^ / ______________________________________________
M /ys y /} / N _ .
Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of Sri/Smt. ______________________
subscriber No. __________________

/ ________________________________ As/ A ________________________

i Q yMtr, y . ________________ ( ________________ )
________________ . ________________ V ^NP / y.y. AMr CV Ag.
I, _________________________________ hereby acknowledge receipt of Rs. ____________
(Rupees ______________________ only) from the ____________ Directorate of Insurance, Hyderabad per
self Sri/Smt. __________________ Attorney / Bearer for Cheque / D.D. No. ______________ Dated
__________________ .

M N M

/ M M y r

Signature of Receipient

Signature or thumb-impression of the policy holder/claimant

/ ________________________ ^ M / ^r ^ / CV
.
I hereby certify that the above signature / thumb impression of Sri / Smt. _________________________
is made in my presence.

Vhsy AM
Name of the Gazetted Officer

Designation

M} : M AM M
Date of attestation Signature of Certifying Officer

M OFFICE SEAL
________________________ _ BV ^NP MVV Agy.
On the strength of certification of _____________________ the above cheque is delivered personally.

syr

i Q Atr yMt

Clerk

Superindent

Asst. Director of Insurance