FORM G
[See sub paragraph (6) of paragraph 12]
Application for withdrawal by Nominees/Legal Heirs under the Public Provident Fund Scheme, 1968

To
The Agent/Manager/Postmaster
………………………….. (Name of the Bank/Head Post Office)
I/We …………………………………………………. the nominee(s)/legal heir(s) of late
……………………… the subscriber to Public Provident Fund Account No………………….. wish to
withdraw the entire amount sanding to the credit of the deceased in the said account.
Please find enclosed
(i) A certificate in regard to the death of subscriber
(ii) Certificate in regard to the death of Sri…………………………………………………
and Sri ……………………………………………………….. also the nominee(s)
appointed by the subscriber
(iii) Succession Certificate/Letters of Administration with attested copy of probated will of
the deceased issued by ………………………….. High Court
(iv) Passbook of the subscriber
@ (v) Letter of indemnity
@ (vi) Affidavit
@ (vii) Letter of disclaimer on affidavit
Place Signature(s)/Thumb impression of Claimant
Date
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TO BE USED BY THE ACCOUNTS OFFICE
Withdrawal of Rs…………….. (Rupees ………………………….…………………….) is sanctioned.
Date …………………… Signature of Accounts Officer
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RECEIPT TO BE SIGNED BY THE CLAIMANT(S)
Received the sum of Rs………………………… (Rupees
……………………………………………………………………………………………………..) from
the State Bank of …………………………………………………….. in full settlement of our claim.
Place Signature(s)/Thumb impression of Claimant
Date
Delete if not applicable
Strike off if there is a valid nomination
@ To be produced by legal heirs, in the absence of nominations for claims upto Rs.1 lakh
ANNEXURE I TO FORM G
(Letter of Indemnity)
To
The Manager/Postmaster
……………………………….
……………………………… (Name of the Bank/Head Post Office)
In consideration of your paying or agreeing to pay me/us ……………………………………….
………………………………………………………………………………………………………………
(Names of Legal heirs) the sum of Rs………………………… standing in Public Provident Fund Account No………………….. with your Bank in the name of ………………………………. Without production of letters of administration or a succession certificate to the estate of the deceased ………………………………. (Name of the subscriber) or a certificate from the Controller of Estate Duty to the effect that estate duty has been paid or will be paid or none is due, I/We …………………….
and we ………………………………. (sureties) do hereby for ourselves and our heirs, legal representatives, executors and administrators jointly and severally undertake and agree to indemnity you and your successors and assigns against all claims, demands, proceedings, losses, damages, charges and expenses which may be raised against or incurred by you by reason or in consequence of having agreed to pay/or paying me/us the sum as aforesaid.
In witness whereof we have hereunto set your hands at ………………………………………… on this ……………………………………………………………………… day of ……………………..
in the presence of witnesses.
Signed and delivered by the above named
Heir/heirs of the deceased
Signed and delivered by the
Above named sureties
1
2
Names and addresses of witnesses
1
2 Attested
Notary Public
ANNEXURE II TO FORM G
(Affidavit)
To
The Manager/Postmaster
……………………………….
……………………………… (Name of the Bank/Head Post Office)
I/We ……………………………………………… Husband/Wife of late …………………….
aged ………, ………….. aged ……………. aged, …………………… sons/daughters of the said late …………………… resident of ……………….. do hereby declare and solemnly affirm as under :-
(1) That I/we am/are the only heir(s) of the deceased ……………………………… who died at ……………………………… on ……………………… I/we alone represent the estate of Sri/Smt …………………………………………
(2) That the deceased ……………………………………….. did not leave any will and therefore
I/we am/are the only successor(s) to the estate of the said deceased
1
2
3
4
DEPONENTS
Verification : I/We, the above named deponents do hereby verify on solemn affirmation in ……………
(name of place) that the contents of this affidavit are true to our knowledge and nothing material has
been concealed.
Dated : 1
2
3
4
Attested
Oath Commissioner DEPONENTS
ANNEXURE III TO FORM G
(Letter of disclaimer on Affidavit)
To
The Manager/Postmaster
……………………………….
……………………………… (Name of the Bank/Head Post Office)
I/We ……………………………………………… Husband/Wife of
………………………………………………………………residents of ………………………………..
(ii) ……………………………………………… son/daughter of …………………………………….
(iii) ………………………………………………...son/daughter of ……………………………………do
hereby solemnly affirm as follows :-
(1) That Sri/Smt …………………………………………….. died instate on ……………………
leaving behind us …………………………….. his only heirs.
(2) That we ………………………… heirs of our late father/mother for ourselves and on behalf of our heirs, executors, representatives and assigns do hereby relinquish our claims to the balance of Rs……………………….. which may be credited to the account sought by our mother/father to be opened in your branch in the name of he estate of the said …………………………….. deceased father/mother after the realisation of Draft No………………. on ………………………. issued by ………………………………………………………………. (name of Bank) and we have no objection whatsoever in the balance in the above referred account no…………………….. together with interest, if any, accrued thereon being paid by the Bank to our said mother/father Mrs/Mr ………………………..
1
2
3
DEPONENT(S)
Verification : I/We, the above named deponent(s) do hereby verify on solemn affirmation that the
contents of this affidavit are true to my/our knowledge
Dated : DEPONENT(S)
I identify the deponent(s) who is/are personally known to me
and who has/have signed in my presence
Dated :
Attested
Oath Commissioner
(Annexure I to III to Form G added vide Ministry of Finance (DEA) Notification No.F-3(6)PD/86 dated 23/03/1986)