DECLARATEON

An aduance Payment cf Provident Funfi balance (in my Generai Provident Fund

Acco!.rnt No E.Dr\t....) ( "I73 7 ...........) having been agreed to be authorized in myfavour

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( [*{arne anc, designation ) hereby declare that I clearly understand that the payrnent is
sirictly provisional and is subject to revision after the exact amount of balance of my
t-ieneial provident Fund Account has bee* decided up on and I undertake tha( if, upon such
ravision, any payment of the General Provident Fund balanee madeto me has been exeess
qf th*! amount eventueily decided upon. i shall ready all Sueh exce$s payments by deduction
frorn nry Deatl! cum - Retirement Gratuity a nd / or Pension. The pafticulars of my Pension
Paymenl orler arc given below

PP.O. Siunrtrer

Data of lssue
q
Treasury

Amount of penslon
ff; *

ol Arat"
sig - firu(
Station............
is{a\a
Address of t
Date
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Adilre.qs and Oecupation of the \Alitness:

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AssL DvokssoY v'uffi;;
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(2)
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Date)
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Note : The witness should be Grvernmerrt empleyees in setvice'