ANNEXURE

STATEMENT THE CREDIT AND WITHDRAWALS FOR THE PERIOD AFTER

THE LASR CREDIT CARD TILL DATE OF APPLICATION FOR N.R.A/CLOSURE
TEMPORARY ADVANCE /OF G.P.F. /K.A.S.E. P.F. A/C

Name of Subscriber: P.F. A/C. No:

A. DEPOSITS
madeMonths of salary from which deduction was

Total amount deducted for the month

Date of the encashment of the bill

Gross amount of the bill

Net amount of the bill

Name of the Treasury

Monthly subscription

No. of installments
Refund of advance

Remarks
Sl:No

1 2 3 4 5 6 7 8 9 10 11
1
2
3
4
5
6
7
8

Total
B. Details of D.A Credited GPF/K.A.S.E.P.F. (Based on which withdrawals is
allowed) Since Last Credit Card
 Gross amount of the bill

Net amount of the bill

Sl:No

Amount credited to PF

billDate of encashment of the

No. and date of G.O.as per

Name of the Treasury

Period to which the arrears
which DA

release

Total

C. Details of withdrawals made after the last credit card

No. and Name of
Date of Name of
date of Amount advance TA Purpose
drawal Treasury
sanction or NRA

Total

If there is no withdrawal since the last credit card that fact should be stated in Proforma

D.ABSTRACT
1. Total amount at credit as per
the last credit card for the year

Less: DA arrear to be deducted

2. Total amount credited to PF account

after last credit card (A+B)

3. Grand Total (item 1+2)

4. Deduct amount of advance drawn

after the issue of last credit Card
(Vide details furnished under C above)
5. Net balance of the subscriber (3-4)
on the date of application

Credited that the particulars furnished above have been verified with reference to
pay abstract, acquittance roll, GPF pass book and other connected records and found
correct.

Signature of Drawing and Disbursing

Officer/Signature of subscriber in case
of the Gazetted Officer

Place: Name:
Date: Designation: