FORM J

[See rules 28(5), 39(1), (2) & (3)]

*APPLICATION FOR CLOSURE OF GENERAL PROVIDENT FUND

(KERALA) ACCOUNT

1. Name (in full), office address of Subscribe :

account number and reference number
(as indicated in the latest annual account
statement received from the Accountant
General with Section & Branch

2. (a) Designation (Specify whether Gazetted or :

Non-Gazetted)
(b) Date of Birth :
(c) Date of joining service :
(d) Home Address with contact number :
(e) If the subscriber is an employee of the
Education Department: whether the
subscriber is a Surrendered School Teacher

3. (a) Office in which the subscriber is working/

worked last
(b) District in which the subscriber is :
working/worked last

4. (a) Date of proceeding on leave preparatory :

to retirement
(b) Date of quitting service by retirement/ :
superannuation
(c) Statement of option as required in rule 28(6) :
[see Note 4 below]

(If he/she has already quitted service

otherwise specify whether he/she has quitted
service by discharge, dismissal, resignation or
death etc.)
 5. In case of 4 (b) whether he/she has drawn :
his/her salary for the month immediately
preceding the month of retirement, if so,
furnish the date of drawal of the salary.
6. (a) Whether the Statement of deposits and :
withdrawals after the period, which has
been included in the latest credit card till
the month in which the Provident Fund
subscription is discontinued, is furnished;
(b) Periods, if any, during which no :
subscriptions and refund of advance have
been recovered due to Leave without
allowance etc.
7. (a) Number and date of the bill/treasury :
voucher in which the last Provident Fund
deduction was made. (Also indicate the name
of the treasury where the bill/voucher was
encashed).
(b) the amount of last fund deductions:—
(i) Subscription `
(ii) Refund of advance ` :
(c) Gross amount of the bill/treasury voucher :
(d) Net amount of the bill/treasury voucher :
(e) Date of encashment of the bill/treasury :
voucher
8. (a) Whether any temporary advance was :
sanctioned to him/her from his/her GPF
(Kerala) account during the twelve months
immediately preceding the date of
application for closure of the account on
his/her quitting service. (if so, indicate the
amount of the advance, the number and the
date of sanction and the date of drawal of
the amount)
 :
(b) Whether any non-refundable withdrawal
was sanctioned to him/her from his/her P F
account during the twelve months
immediately preceding the date of
application for closure of account on his/her
quitting service, (if so, indicate the amount
of advance, number and date of sanction
and the date of drawal of the amount).

†9. Whether personal marks of identification, left :

hand thumb and finger impressions and
specimen signature in duplicate, duly attested by
a Gazetted Officer of the State Government have
been furnished. (In respect of a Gazetted
Officer, specimen signature in duplicate, duly
attested by another Gazetted Officer alone need
be furnished.)

‡10. Name of the treasury/office through which :

payment is to be made

11. A. In the event of death of a subscriber before :

making final disbursement of the PF
amount, furnish also:

(a) Date of birth of the subscriber :

(b) Date of his/her first appointment in the :

Government service

(c) Date of death :

(d) Whether proof of death in the form of a death :

certificate issued by the Municipal authorities
or other competent authorities is available.
(The proof of death need be insisted upon
only in cases of doubt.)

(e) Whether a valid nomination executed by the :

subscriber in accordance with the rules exists.
[If so, attach the nomination in original].
 (f) In the case of subscriber who filed his/her :
nomination while unmarried, whether
he/she has acquired a family after the
submission of the first nomination and
whether he/she has submitted a fresh one
thereafter.

B. If there is no valid nomination, furnish a list of :

member (s) of the subscriber’s family as
defined in Rule 2 (c) of the GPF (Kerala) Rules
surviving on the date of death of the subscriber
to whom the PF money is payable together with
his/her/their name(s), age(s) and respective
relationship to the subscriber, with
Departmental Enquiry Certificate (DEC). [In
the case of daughter(s), indicate whether
she/they is/are married or unmarried. If
married, furnish whether her/their husband(s)
is/are alive.]

C. In case where there is no valid nomination and :

where no member of the family of the
subscriber as defined in rule 2 (c) of the GPF
(Kerala) Rules survives, furnish the name(s) of
the person(s) to whom the PF money is payable
(to be supported by letters of probate or
succession certificate, etc.)

12. Whether a fresh nomination has been enclosed :

with the closure application (The subscriber is
required to file a fresh nomination and enclose
the same with the closure application)
 § DECLARATION

I,…………………………………. do hereby declare that the particulars mentioned above are

true. I further declare that I do not/do accept the balance standing to my credit in the GPF
(Kerala) Account No……………………..communicated to me by the Accounts Officer in his
annual account statement for the financial year ended on the 31st March 20.. …… ¶
…………………..(here enter the financial year immediately preceding the date of his quitting
service).

Station : Dated Signature of the subscriber/

Date: Nominee(s)/other claimant(s) with full home address.

(To be filled in by Head of Office/Department)

CERTIFICATES

(1) Certified after due verification with reference to the records available in my office
that Shri/Smt………………………subscriber to PF account No……………. has
proceeded on leave preparatory to retirement with effect
from………………………F.N/A.N. will be retiring/has already retired/has been
discharged/dismissed/removed/has resigned finally from Government service with
effect from………….F.N./A.N. and his/her resignation has been accepted. He/she
has drawn on ………….. his/her salary for the month immediately preceding the
month of retirement.
@ Certified also that he/she has not resigned from Government Service with the
prior permission of the Government to take up appointment in another department of
the State Government or under the Central Government or under any other State
Government or under a body corporate owned or controlled by Government or an
autonomous organisation, registered under the Societies Registration Act, 1860.
(2) Certified further after due verification with reference to the records available in my
office that no temporary advance/ non-refundable withdrawal was sanctioned to the
subscriber from his Provident Fund account during the 12 months immediately
preceding the date of his application for closure of the account/quitting service.
Certified also after due verification with reference to the records available in my
office that the following temporary advance(s)/ non-refundable withdrawal(s)
was/were sanctioned to the subscriber from his/her Provident Fund account during
the twelve months immediately preceding the date of his/her application for the
closure of PF account/ quitting service.
 Amount of Amount of non- No. and Date of Voucher No.
temporary refundable date of withdrawal
advance` withdrawal` sanction

(3) Certified that the last Fund deduction was made from his /her pay for the month
of……………….. drawn in this office bill No…………….. dated ………………for
` …………….. (Rupees…………………) Voucher No………..of ………Treasury, the
amount of deduction being ` …………………….. and recovery on account of
refund of advance being `……………………………………….
(4) Certified also that the entry against items 1,2,3 and 7 furnished by the claimant(s)
have been verified by me with reference to my office records and found correct
(5) Certified also that the entry against column 11 B furnished by the claimant(s) has
been verified by me and found correct to the best of my knowledge.
(6) Certified that the application for pension is being processed in this office/details of
Pension payment order noted below are correct.

Signature of Head of Office/ Department

Station: ** (Dated, Counter-signature of the Gazetted Superior Officer).

Date:

*The form shall be carefully filled in by the subscriber as soon as his/her salary
for the month immediately preceding the month in which he/ she retires or proceeds
on leave preparatory to retirement on superannuation is received by him/her and
submitted to the Head of the Office or Department according as the subscriber is
Non-Gazetted or Gazetted.

In the case of a subscriber who is no more, the Head of the Office or Department
shall according as the subscriber is non-Gazetted or Gazetted obtain from the
nominee(s) or in his/her/their absence from the other claimant(s) immediately after
the death of the subscriber, an application for closure of the account and to forward it
with necessary documents to the Accountant General within the fortnight of the
 receipt of the application. The Departmental Officers will give such assistance to the
nominees or claimants as is necessary to fill in the form of application properly.

† It applies only when payment is desired at a treasury other than the one at the
District Headquarters where the subscriber served last’

‡ In respect of non-Gazetted Officers, the payment will not be made through the
treasury, but only through the Head of the Office in which he/she served last’

§ If the application is submitted by a nominee or other claimants, the second

sentence in the declaration may be scored off.

¶ If the subscriber has not received the annual account statement for the financial
year immediately preceding the date of his/her quitting service, he/ she may indicate
here the year of the latest annual account statement received by him/ her. In case
where the subscriber does not accept the balance communicated to him/ her, he/ she
should furnish briefly in a separate letter the reasons for not accepting the balance.

@ This certificate is not necessary in cases other than resignation.

** If the Head of Office forwarding the application is non-Gazetted, the

application should be routed through his/her immediate Gazetted superior who shall
countersign the application.

Note: — 1. In case the subscriber is a Gazetted Officer, the certificates relating to the date of
retirement, details of advances sanctioned and alone certificate regarding the
correctness of the entries in items 1, 2 and 3 (i.e. certificates Nos. 1, 2 and 4) also need
be furnished by the Head of Department or any other authority competent to sanction
temporary advances and non-refundable advances from the PF of the subscriber.

Note: —2. Item 7 need be filled up in the case of Gazetted Officers.

Note: —3. Certificate 3 need be filled up in the case of non-Gazetted Officers/ Nominees/
Claimants.

Note: —4. A subscriber who wishes to avail of the facility of discontinuance of subscription
under Rule 7(d) and for the withdrawal of the available balance before retirement under
Rule 28(6) shall furnish the option statement against item 4(c).