FORM-11

Application for Part Final Withdrawal from GPF

1. Name of the Subscriber :

2. Account Number :
3. Designation (with Division) :
4. Pay :
5. Date of joining service and the date of :
superannuation
6. Balance or credit of the subscriber on the :
date of application as
(1) Closing balance as per statement for :
the year
(2) Credit from March to ___________ @ :
Rs.______________ per month on
account of monthly subscription
(3) Refunds made to the fund after the :
closing balance vide (1) above
(4) Withdrawal during the period From :
___________ To ______________
(5) Net balance at credit on date of :
application
7. Amount of withdrawal required :
8. (a) Purpose for the withdrawal is required :
(b) Rule under which request is covered :
9. Whether any withdrawal was taken for :
same purpose earlier it so; indicate the
amount and the year
10. Name of the account officer maintaining the :
provident fund account

Date : ____________ Signature of Applicant

Name ____________________________

Designation _______________________

Division/Section ____________________

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