Form No4

FORM NO. IV STATEMENT OF PROVIDENT FRUND AND LIFE INSURANCE POLICY HELD BY GOVERNMENT SERVANT PROVIDENT FUND.AS ON 1.12.2001 Sl.No. Policy Name Sum Amount Type of Closing balance as Contributio Total Remarks (if there in No.an Insurance Assured/ of Provident last reported by the ns made dispute regarding d Date Company Date of annual Fund audit/accounts officer subsequentl closing balance of maturity GPF/GPF along with date of y figures according to policy Account such balance the Govt. service No. should also be mentioned in the coloumn. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

SIGNATURE