Schedule2 – Employees State Insurance Corporation (General Provident Fund) Rules, 1995

SCHEDULE II: Application for Advance / Withdrawal from General Provident Fund

[Rules 14(3) and 17(1)]

1. Name of the subscriber………………….

2. Account number ………………………….

3. Designation ……………………………

4. (1) Pay Rs ………………………………

(2) Monthly subscription Rs ………..

5. In case of withdrawal

(i) Date of birth ………………………..

(ii) Date of appointment ………………………..

(iii) Date of superannuation…………………….

Balance at credit of the subscriber on the date of application as below:-

(i) Closing balance as per statement for the year 19……. Rs……

(ii) Credit from ………..to…….. on account of monthly subscription Rs …………

(iii) Refunds Rs………………………..

(iv) Withdrawals during the period from….. to….. Rs………

(v) Net balance at credit Rs…………………

6. Amount of advance outstanding, if any, and the purpose for which advance was taken by them-

Amount of advance taken Rs …………………

Balance outstanding as on date Rs …………

7. Amount of advance required Rs

8. (a) Purpose for which the advance is required…………..

(b) Rules under which the request is covered……………

(c) If advance is sought for house building, etc. following information may be given:-

(1) Location and measurement of the plot ……………..

(2) Whether plot is freehold or on lease………………..

(3) Plan for construction …………………………………..

(4) If the flat or plot being purchased is from a H.B. Society, the name of the society, the location and measurement, etc……………

(5) Cost of construction ……………….

(6) If the purchase of flat is from DDA or any Housing Board; etc. the location, dimension, etc, may be given………………

(d) If advance is required for education of children, following details may be given:-

(1) name of the son / daughter…………….

(2) Class and institution / college where studying………….

(3) Whether a day-scholar or a hosteller……………..

(e) If advance is required for treatment of ailing family members, following details may be given:-

(1) Name of the patient and relationship……………………

(2) Name of the Hospital/ Dispensary/ Doctor where the patient is undergoing treatment …..

(3) Whether outdoor / indoor patient ………….

(4) Whether reimbursement available or not……………………….

Note: In case of advance under 8(c) to 8(e), no certificate or documentary evidence would be required.

9. Amount of the consolidated advance (Item 6 and 7) and number of monthly installments in which the consolidated advance is proposed to be repaid Rs. ____ in installments.

10. Full particulars of the pecuniary circumstances of the subscriber, justifying the application for the advance.

I certify that the particulars given above are correct and complete to the best of my knowledge and belief and that nothing has been concealed by me.

Signature of Applicant

 Name _____________________

Recommendation / remarks of the                       Designation ________________

competent authority                                        Section / Branch ___________
_

Dated_____                                                   Signature __________________

                                                            Designation ________________

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