My Chidhood Memoreis

Proforma for application for withdrawal from provident fund
Tagore Educational Institute,
Kothambi, Pale, Goa.
Pin. Code No. 403 105.

Application for withdrawal from : GENERAL PROVIDENT FUND (Here Enter the name of the Fund) 1. Name of the Subscriber : MR. BHISO H. GAUNS 2. Account No. : NEZ/089/
Designation (With departmental suffix) : Asstt. Teacher
Pay (Basic Pay) :
Date of Joining Service and :
Date of superannuation :
Balance at the Credit of the Subscriber
On the date of the application as below:- 1. Closing balance as per the Statement
For the year ____ 2011-12____ : 2. Credit from March 2012 to December 2012
On account of monthly subscription
Rs. 1000/- : Rs. 10,000/- 3. Refund made to the fund after
The closing balance vide (1) above : -- NIL -- 4. Withdrawal during the period
_____________ to ___________ : -- NIL -- 5. Net balance at credit on the date of
Application :
Amount withdrawal required : Rs. a) Purpose for which the
Withdrawal Required : For purchase consumer goods b) Rule Under which the :
Request is covered
Whether any withdrawal was taken for the same purpose earlier. If so, indicate Amount and the year
Name of the Accounts Officer : Directorate of Accounts,
Maintaining the Provident Fund Account Panaji – Goa.

Signature of the Applicant
Date: _____________ Name: Mr. Bhiso H. Gauns
Designation: Asstt. Teacher

Manager Headmaster

PROFORMA
UNDERTAKING FROM GPF SUBSCRIBER

I, the undersigned Mr. Bhiso H. Gauns, Asstt. teacher hereby state that I will utilize GPF withdrawal amount to the purpose for which it is withdrawn. The necessary utilization documentary evidence such as cash memos, bills etc., will be produced within a reasonable time. In case I fail to do so, the whole of sum so withdrawn will be refunded in one lump sum. In default of such payment, you may recover the whole amount through my full monthly salary.

Place: Kothambi - Pale Signature:
Date: _______________ Name of the subscriber: Mr. Bhiso H. Gauns Designation: Asstt. Teacher Name of the school: Tagore Educational Institute, Kothambi-Pale-Goa.

TAGORE EDUCATIONAL INSTITUTE,
KOTHAMBI – PALE, GOA.

VERIFICATION CERTIFICATE

This is to certify that the General Provident Fund Account No. NEZ/089/02 of Mr. Bhiso H. Gauns, Asstt. Teacher of this High School amounting to Rs._______________ (Rupees _______________________________________ only) has been verified and found correct as per records maintained by this school.

Place: Kothambi-Pale,
Date: /01/2013.

Manager, Headmaster,
Tagore Educational Institute, Tagore Educational Institute,
Kothambi – Pale – Goa. Kothambi – Pale – Goa.

Certificate

Certify that, the balance at the credit of the subscriber Mr. Bhiso H. Gauns, Asstt. Teacher of this School on the date of withdrawal covers sum required to be withdrawn as withdrawal.
Certify that, the amount claimed in the application is not drawn or paid previously.

Place: Kothambi
Date: /01/2013 HEADMASTER