FORM 1.
[Rule] 4(3)]

When the subscriber has a family and wishes to nominate one member thereof-
I hereby nominate the person mentioned below, who is a member of my family as defined in rule 2 of the All India Service (Provident Fund) Rules, 1955, to receive the amount that may stand to my credit in the Fund, in the event of my death before that amount has become payable, or having become payable has not been paid:-
Name and relationship address of nominees Relationship with subscriber Age/Contigencieson the happening of which the nomination shall become invalid Name, address of the person or persons if any to whom the right of the nominee shall pass in the event of his predeceasing the subscriber
Dated this day of 19 at two witnesses to signature
1.
2.

Signature of Subscriber.

FORM II
[Rule 4(3)]
When the subscriber has a family and wishes to nominate more than one member thereof-
I, hereby nominate the persons mentioned below, who are members of my family as defined in rule 2 of the All India Services(Provident Fund) Rules, 1955, to receive the amount that may stand to my credit in the Fund, in the event of my death before that amount has become payable, or having become payable has not been paid, and direct that the said amount shall be distributed among the said persons in the manner shown below against their names:-
Name and relationship address of nominees Relationship with subscriber Age/Contigencieson the happening of which the nomination shall become invalid Name, address of the person or persons if any to whom the right of the nominee shall pass in the event of his predeceasing the subscriber
Dated this day of 19 at two witnesses to signature
1.
2.

Signature of Subscriber.
(or on the happening of the contingency or contingencies specified in the previous columns deleted vide M.H.A. Notification No. 5/10/59-AIS(II), dated the 19th August, 1959----------------------------------------------------------------------------------------

FORM III
[Rule 4(3)]
When the subscribe has no family and wishes to nominate one person- I, having no family as defined in rule 2 of the All India Services (Provdent Fund) Rules, 1955, hereby nominate the persons mentioned below to receive the amount that may stand to my credit in the Fund, in the event of my death before that amount has become payable, or having become payable has been paid:-

Name and relationship address of nominees Relationship with subscriber Age/Contigencieson the happening of which the nominationshall become invalid Name, address of the person or persons if any to whom the right of the nominee shall pass in the event of his predeceasing the subscriber
Dated this day of 19 at two witnesses to signature
1.
2.

Signature of Subscriber.

FORM IV
[Rule 4(3)]
When the subscriber has no family and wishes to nominate more than on person-
I, having no family as defined in rule 2 of the All India Services Provident Fund) Rules, 1955, hereby nominate the persons mentioned below to receive the amount that may stand to my credit in the Fund, in the event of my death before that amount become payable, or having become payable has not been paid, and direct that the said amount shall be distributed among thesaid persons in the manner shown below against their names:-

Name and relationship address of with nominees subscriber Age Amount or share of accumulation to be paid to each Contigencies on the happening of which the nomination shall become invalid Name, address and relationship of the person or persons if any to whom the right of the nominee shall pass in the event of his predeceasing the subscriber 106
Dated this day of 19 at two witnesses to signature
1.
2.

Signature of Subscriber.

NOTE: Where a subscriber who has no family makes a nomination, he shall specify in this column that the nomination shall become invalid in the event of his subsequently acquring a family.
FORM IV A
[Rule 12(3)]
When the subscriber wishes to take part-final withdrawal.
Shri...........................was last sanctioned a prat-final withdrawal by this office for an amount of Rs..........vide..........after the statement of his accounts for the year............was issued by the Accounts Officer.
---------------------------------------- Signature of sanctioning Authority.
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FORM IV B
[Rule 12 (3)]
When the subscriber wishes to take part-final withdrawal.
Shri..................is understood (as stated by him) to have been last sanctioned a part-final withdrawal of Rs.............by..............

Signature of sanctioning Authority.
FORM V
32[Rule 21(1)]
FORM VI
[Rule 21(1) (a)]

I, A.B. of.............. herby assign unto the President of India /Governor of the State of............the within policy of assurance as security for payment of all sums which under rule 25 of the All India Service (Provident Fund) Rules, 1955, I may hereafter become liable to the All India Services Provident Fund.
I hereby certify that no prior assignment of the within policy exists.
Dated this.............day of..........19
Station

Signature of Subscriber.
One witness to signature.

FORM VII
[Rule 21(1) (a)]

We, A.B. (the subscriber)of...........and C.D. (the joint assured) in consideration of the ..........*1 President of India/
Governor of the State of.............agreeing at our request to accept payments towards the within policy of assurance in substitution for the subscription payable by me the said A.B. to the All India Services Provident Fund (or, as the case may be, to accept the withdrawal of the sum of Rs.......from the sum to the credit of the said A.B. in the All India Services Provident Fund for payment of the premium of the within policy of assurance), hereby jointly and severally further assign unto the said.
*President of India/Governor of the State of...........the within policy of assurance as security for payment of all sums which under rule 25 of All India Services (Provident Fund) Rules, 1955, the said A.B. may hereafter become liable to pay to that Fund.
We hereby certify that no prior assignment of the within policy
exists.
Dated this ...............day of.....19
Station
Signature of Subscriberand the Joint Assured, One witness of signature.
Note. - The assignment may be executed on the policy itself either in the subscriber's handwriting in type or alternatively a type or printed slip containing the assignment may be pasted on the blank space provided for the purpose on the policy. A type or printed endorsement must by duly signed and if kpasted on the policy, it must be initialled across all four margins.

FORM VIII
[Rule 21(1)(a)]
I. C.D., wife of A.B., and assignee of within policy, having, at the request of A.B. the assured, agreed to release my interest in the policy in favour of A. B., in order that A.B. may be assign the policy to the.........
*President of India/Governor of the State of.......who has agrred to accept pyments towards the within policy of assurance in substitution for the subscriptions payable by A.B. to the All India Services Provident Fund hereby at the request and by the direction of A.B. assign and I the said A.B. assign and confirmed unto the
*President of India/Governor of the State of......the within policy of assurance as security for payment of all sums which under rule 25 of the rules of the Fund the said A.B. may thereafter become liable to pay to the Fund.
We hereby certify that no prior assignment of the within policy; exists.
Dated this......day of......19
Signature of the assignee and the subscriber.
One witness to signature.
*Strike off the alternative which does not apply.

FORM IX
[Rule 21(1)(a)]
I, A.B. of ....................hereby further assign unto the
11 President of India/Governor of the State of...............the within policy of assurance as security for payment of all sums, which under rule 25 of the All India Service (Provident Fund) Rules, 1955, I may hereafter become liable to pay to the All India Services Provident Fund.
I hereby certify that except an assignment to the *President of India/Governor of the State of..............as security for payment of all sums, which I have become liable to pay under rule.............of the ...........Provident Fund Rules, no prior assignment of the within policy exists.
Dated this.........day of..........19
Station

Singnature of Subscriber
One witness to signature.

*Strike off the alternative which does not apply

FORM X
[Rule 21(1)(a)]
We, A.B. (the subscriber) of.............and C.D. (the joint assured) of.........in consideration of the.................
*President of India/Governor of the State of ............agreeing at our request to accept payments towards the within policy of assurance in substitution for the subscriptions payable by me the said A.B. to the All India Services Provident Fund (or, as the case may be, to accept the withdrawal of the sum of Rs......... from the sum to the credit of the said A.B. in the All India Services Provident Fund for payment of the premium of the within policy of assurance), hereby jointly and severally further assignment unto the said.
*President of India/Governor of the State of......... the within policy of assurance as security for payment of all sums which under the rule 25 of the All India Services (Provident Fund) Rules, 1955, the said A.B. may hereafter become liable to pay to the Fund.
We hereby certify that except an assignment to the *President of India/Governor of the State of...........as the security for payment of all sums, which the said A.B. has become liable to pay under rule ...........of the ...............Provident Fund Rules, no prior assignment of the within policy exists.
Dated this.............day of............19
Station
Signature of Subscriber, and joint Assured,
One witness to signature.

FORM XI
[Rule 23(1)(i)]

All sums which have become payableby the above named. A.B. under rule 25 of the All India Services (Provident Fund) Rules, 1955, having been paid and all liability for payment by him of such sum in the future having ceased, the...............
*President of India/Governor of the State of..............doth here by reassign the within policy of assurance to the said *A.B. and C.D.
A.B.
Dated this ............day of........19
Executed by ............Account Officer of the Fund for

*President of India
and on behalf of the-----

Governor of the State of.....in the presence of
X.Y.
(Signature of Account Officer)
(One witness who should add his designation and address).

FORM XII
[Rule 24(1)(i)]
The above-named A.B. having died on the.........day of.....19, *President of India/Governor of the State of........doth hereby reassign the within policy of assurance to C.D.**......... doth hereby reassign the within policy of assurance to C.D. **...................
Date the.........day of.......19........
Executed by........Account Officer of the Fund for and on behalf of the *President of India/Governor of the State of ......... in the presence of
X.Y.
(Signatur of Account Officer)
Y.Z.
(One witness who should add his designation and address).

FORM XIII
[Rule 24(1)(i)]

*President of India/Governor of the State of......both hereby reassign the within polivy of assurance.
A. B.
to-----------
A.B and C.D
Dated the .......day of......19
Executed by .................Account Officer of the Fund for and on
behalf of the *President of India/Governor of the State of .............. in
the presence of
X.Y.
(Signature of Account Officer)
Y.Z.
(One witness who should add his designation and address).
(Signature of Account Officer)
[No. 12/1/54-(II), dated the 12th September, 1955].
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+Introduced vide M.H.A. Notification No. 13/43/57-AIS(III), dated the 27th June 1958 *Strike off the alternative which does not apply
*Strike off the alternative which does not apply

*FORM XIV
[Rule 30(ii)]
Form of application for final payment of balances in the provident fund account of a subscriber to be used by the nominees or any other claimants where no nomination subsits.
To
The Accountant General,
----------------------
(Through the Head of Office)
Sir,
It is requested that arrangements may kindly be made for the payment of the accumulations in the Provident Fund Account of Shri/Shrimati.......... The necessary particulars required in this connection are given below:-
1. Name of the Government Servant.
2. Date of birth.
3. Post held by the Government servant.
4. Date of death.
5. Proof of death in the forms of a death certificates issued by the municipal authorities etc., if available.
6. Provident Fund Account Number allotted to the subscriber.
7. Amount of Provident Fund money standing to the credit of thesubscriber at the time of his death, if known
8. Details of the nominees alive on the date of death of the subscriber if a nomination subsists.
Name of the Nominee
1.
2.
3. Relationship with the subscriber Share of nominee

9. In case the nomination is in favour of a person other than a member of the family, the details of the family if the subscriber subsequently acquired a family.
Name
1.
2.
3. Relationship with the subscriber Age on the date of death

10. In case no nomination subsists, the details of the surviving members of the family on the death of the subscriber. In the case of a daughter or of a daughter of a deceased son of the subscriber, married before the death of the subscriber, it should be stated against her name whether her husband was alive on the date of death of the subscriber.
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*Inserted vide MHA Notification No.5/1/69-AIS(II), dated 1-1-1970. (GSR No. 55, dt. 10-1-70).
Foot Note:- This applies only when payment is not desired through the Head of Office.
Name
1.
2.
3. Relationship with the subscriber Age on the date of death
11. In the case of amount due to a minor child whose mother (widow of subscriber) is not a Hindu, the claim should be supported by Indemnity Bond or Guardianship certificate, as the case may be.
12. If the subscriber has left no family and no nomination subsists, the names of persons to whom the Provident Fund money is payable (to be supported by letter of probate or succession certificate etc.)
Name
1.
2.
3. Relationship with the subscriber Address

13. Religion of the claimant(s)
14. The payment is desired through the office of.....through the ..Treasury/Sub-Treasury. In this connection the following documents duly attested by a Gazetted Officer in Service/ Magistrate are attached.
(i) Personal marks of identification.
(ii) Left/Right hand thumb and finger impressions (in the case
of illiterate claimants).
(iii) Speciman signature in duplicate (in the case of literate
claimants.)
(iv) Photographs in duplicate.

Yours faithfully,
(Signature of claimant)
Full name and Address

Station ................
Date..................
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(FOR USE OF HEAD OF OFFICE/DEPARTMENT)
Forwarded to the the Accountant General.............for necessary action. The particulars furnished above have been duly varified.
2. The Provident Fund Account No...........of Shri/Smt/Kumari(As verified from the annual statement furnished to him/her)is ...............
3. He/She died on.............A death certificate issued by the Municipal authorities has been produced/is not required in this case as there is no doubt about his/her death.
4. The last fund deduction was made from his/her pay for the month of.........drawn in this office Bill........No...... dated.........for Rs.......(Rupees............) Cash Voucher No........... of........Treasury the amount of deduction being Rs........... and recovery on account of refund of advance Rs............
5. Certified that he/she was neither sanctioned any temporary adcance nor any final withdrawal from his/her Provident Fund Account during the 12 months immediately preceding the date of his/her death.
OR
Certified that the following temporary advances/final withdrawals were sanctioned to him/her and drawn from his/her Provident Fund Account during the 12 months immediately preceding the date of his/her death.
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Amount of advances /withdrawal
1.
2.
3. Date of place of encashment Voucher No.

6. Certified that no amount was withdrawn/the following amounts were withdrawn from his/her Provident Fund Account during the 12th months immediately preceding the date of his/her death for payment of insurance premia or for the purchase of a new policy.
Policy No. and name of the company
1.
2.
3. Amount Date Voucher No.
7. It is certified that no demands of

------------------
following demands
Government are due for recovery.
(Signature of the Head of Office/Deptt.)
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Note.- Certificate No. 7 to be furnished in the case of C.P.F. only
"FORM" XV"
[Rule 31(1)]
Form of Application for Final Payment/of Balances in the------------ Provident Fund Account.
To
The Pay and Accounts Officer/Accountant General,
________________________________________________
(Through the Head of Office)
Sir,
I am due to retire/have retired/have proceeded on leave preparatory to retirement for ---------months/have been discharged/dismissed/have permanently been transferred to service/have resigned service under----------Government to take up appointment with ------------ and my resignation has been accepted with effect from______ forenoon/afternoon, I joined service with____________on__________forenoon/afternoon.
2. I request that the entire amount at my credit with interest due under the rules may be paid to me through____Treasury/Sub-Treasury. My Provident Fund Account No. is _________________
PART-I
(To be filled in when the application for final payment is submitted upto one year prior to retirement.)
3. An amount of Rs.________stood to the credit in my Provident Fund Account as indicated in the Accounts statement issued to me for the year _________as appearing in my ledger account being maintained by you. I request you that my Provident Fund Account may be reviewed and brought up-to-date.
4. The undermentioned Life Insurance Policies were being financed by me from My Provident Fund Account.
Number Name of the Company Sum assured.
1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
5. I will make another application immediately after last fund deduction has been made from my salary, in part II of the Form.
Yours faithfully,
Signature--------
Station___________
Date_____________
Name_____
Address____

(FOR USE BY HEADS OF OFFICE)
Forwarded to the pay and Accounts officer/Accountant General,_____for necessary action.
2. The Provident Fund Account No. /of Shri/Smt./Kum.__________ as verified from the statement issued to him/her from year______________.
3. He/She is due to retire form Govt. Service with effect from _______afternoon.
4. Certified that he/she had taken the following advances in respect of which______ instalments of Rs.___________are yet to be recovered and credited to the Fund Account. The details of the final withdrawals granted to him/her after the period covered by the aforesaid accounts Statements are as indicated below:-
Temporary advances Final withdrawals
1.______________ __________
2.______________ __________
3. _____________ __________
Signature of the Head of Office

PART II
(To be submitted by the subscriber immediately after the last fund deduction has been made from his salary. This part is also applicable in the case of subscribers who apply for final payment for the first time after the date of superannuation, discharge, resignation etc.)
In continuation of my earlier application, dated for_________ for the final payment of Provident Fund balance, I request that entire balance at my credit with interest due under the rules may be paid to me.
OR
I request that the entire amount at my credit with interest due under rules may be paid to me/transferred to_________

Signature_______
Name______
Address_____
(FOR USE BY HEADS OF OFFICERS)

Forwarded to the Pay & Accounts officer/Accountant General, _______for necessary action/ in continuation of endorsement No.___________
2. He/She is due to retire from service on________has proceeded on leave preparatory to retirement for ________months from __________ has been discharged/dismissed permanently transferred to_______ has resigned finally from Government service/has resigned service under_______Government to take appointment with________and his/her resignation has been accepted with effect from________forenoon/afternoon. He/she joined service with ______on________fornoon/afternoon.
3. The last fund deduction was made from his/her pay in this office Bill No.____ dated_______ for Rs________(Rupees)--------, Cash Voucher No._____of Treasury, the amount deduction being Rs._________ and recovery on account of refund of advance Rs.___________
4. Certified that he/she was neither sanctioned any temporary advances nor any final withdrawals from his/her provident fund account during the 9 months immediately preceding the date on which the last fund deduction has been made from his/her salary or thereafter.
OR
Certified that the following temparory advances final withdrawals were sanctioned to him/her and drawn from his/her Provident Fund Account during the 9 months immediately preceding the date on which the last fund deduction has been made from his/her salary or thereafter.
Amount of Date Vocher
advance/withdrawal number
------------------ ---- ------
1. -------------------------------------------------------------------
2. -------------------------------------------------------------------
3. -------------------------------------------------------------------

(Signature of Head of Office)

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