2. ò³”¯èþ €ñþÍí³¯èþ ÑÐèþÆæÿÐèþË, f€èþ ç³Ææÿ^èþºyìþ¯èþ §æþÆæÿRêçÜ¢Ìø €ñþÍí³¯èþ ÑçÙÄèÿÐèþË çÜÇÄðÿ”¯èþÐèþ°Äèÿ ò³” €ñþÍí³¯èþ AÐèþçÜÆæÿÐèþ ÌôýMæü A¯èþÐèþçÜÆæÿÐèþË
°Ñ€èþ¢Ðèþ Ðèþ’É€èþÐóþ ò³”MæüÐèþ¯èþ QÆæÿa ^óþÄèÿVæü˯èþ°Äèÿ C™§æþ Ðèþ’ËÐèþ¯èþ Éç³Mæüsìü™^èþ^èþ¯é²¯èþ. ÔéQ °ÄèÿÐèþ’Ðèþã ¯èþ¯èþçÜÇ™_ B™É«æþÉ糧óþÔý É糿æý€èþÓ
ÁÐèþ’ ÔéQ MéÆæÿŧæþÇØMìü °Ææÿ~Æÿ™^èþ 糧æþ®€èþ˯èþ, Ðóþ€èþ¯èþÐèþ ¯èþ™_ º}ýÐèþ, Ðèþyìþz €èþXY™ç³‘˯èþ ^óþÄèÿ E€èþ¢ÆæÿÓË gêÈ ^óþÄèÿrN C™§æþ Ðèþ’ËÐèþVé
ÐéÇMìü A¬MéÆæÿÐèþ C^èþa^èþ¯é²¯èþ.
I hereby declare that the particulars stated above as well as those mentioned in the covering application are
correct and that I shall spend the amount received only on the object or objects, mentioned above. I hereby
authorise the Director Directarate of Insurance Department Government of Andhra Pradesh to pass orders to effect
recoveries of Loan and interest from my salary in the manner as may be prescribed by him in accordance with the
rules of the Department.
€ôþ¨ :
§æþÆæÿRêçÜ¢ §éÆæÿ çÜ™€èþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ Ðèþɧæþ
Date ....... 197
Signature of Thumb Impression of the applicant
ò³” §æþÆæÿRêçÜ¢Ìø €ñþÍí³¯èþ ÑÐèþÆæÿÐèþË ¯éN €ñþÍíܯèþ™€èþ ÐóþÆæÿN ¯óþ¯èþ ÑÔèýÓíÜ™^èþ¯èþ™€èþ ÐèþÆæÿN Äèÿ§éÆæÿ¦ÐèþË°Äèÿ, ò³” çÜ™€èþMæüÐèþ ÌôýMæü »ör¯èþ
ÉÐóþÍ Ðèþɧæþ ...................................................... VéÇ §æþ°Äèÿ C™§æþ Ðèþ’ËÐèþVé «æþ–ÒMæüÇ™^èþyæþÐðþ”¯èþ¨. BÄèÿ¯èþ B™.Éç³.Éç³.i.Á.
ÔéQ ¯èþ™yìþ Ææÿ’. .................................... º}ýÐèþ ¡çÜMö° Äèÿ¯é²Ææÿ. C™§æþË C™Mæü¯èþ’ Ææÿ’. ....................................
Ë »êMîü Äèÿ¯é²Ææÿ.
It is hereby certified that the particulars stated in the above application are correct to the best of my knowledge and belief and that the above signature or thumb/impression is of Shri ...........................................................
He ad obtained a loan of Rs. ........................... from A.P.G.I. Dept. out of which Rs. ..................... are still outstanding.
«æþ–ÒMæüÇ™^èþ Vóühsðütyþ A¬MéÇ çÜ™€èþMæüÐèþ
Signature of the
certifying Gazetted Officer ___________________
€ôþ¨:
«æþ–ÒMæüÇ™^èþ A¬MéÇ õ³Ææÿ
Date ... 197
Name of the certifying Officer _________________
MéÆéÅËÄèÿÐèþ Ðèþɧæþ
çßø§é
Office Seal
Designation _______________________________
VæüÐèþ°Mæü:& §æþÆæÿRêçÜ¢ §éÆæÿ C¨ÐèþÆæÿMóü ÁÐèþ’ ÔéQ ¯èþ™yìþ º}ýÐèþ ¡çÜN¯èþ² ÄðÿyæþË ò³” «æþ–Ðèþ ç³É€èþÐèþò³” §æþÆæÿRêçÜ¢ §éÆæÿ°, AÐèþÅÐèþí߀èþ E¯èþ²€ø§øÅW
çÜ™€èþMæüÐèþ ^óþÄèÿÐèþÌñý¯èþ.
Note:-
In case the applicant has already obtained loan from Insurance the above certificate should be signed by
the applicant's immediate superior.
4. ¯é çÜÐèþ„æþÐèþÌø çÜ™€èþMæüÐèþ ^óþíܯèþ ò³” çÜ™€èþMæüÐèþ & ÐóþÍ Ðèþɧæþ
____________________________ ÐéÇ É«æþÒMæüÆæÿ}ýÐèþ
×/×Ðèþ ......................................................
糑ÆæÿçÜPÇ™^èþMö° ò³” ^ðþNP¯èþ çÜÓÄèÿÐèþVé A™§æþgôýÄèÿyæþÐðþ”¯èþ¨.
¯óþ¯èþ C™§æþ Ðèþ’ËÐèþVé «æþ–Ðèþç³Ææÿ^èþ^èþ¯é²¯èþ.
______________________________________
I hereby certify that the above signature/thumb
impression is of Sri/Smt. ______________________
On the strength of certification of
_______________________________________________
the above cheques reserved personally .
who has signed in my presence.
Væühsðüyæþ A¬MéÇ õ³Ææÿ
1.
Name of the Gazetted Officer______________
___________________________________
___________________________________
çßø§é
2.
çÜ’ç³Ç™sðü™yðþ™r
Designation __________________________
Superintendent
çÜàÄèÿ çÜ™^éËNyæþ, ÁÐèþ’
Asst. Director of Insurance
«æþ–ÒMæüÇ™_¯èþ €ôþ¨
3.
Date of Attestation ______________________
MéÆéÅËÄèÿ糑 Ðèþɧæþ
OFFICE SEAL
VæüÐèþÝë¢
Clerk
«æþ–ÒMæüÇ™_¯èþ A¬MéÇ çÜ™€èþMæüÐèþ
Signature of the Certifying
Gazetted Officer
VæüÐèþ°Mæü:& B™É«æþÉ糧óþÔý çÜÈÓçÜÌø Äèÿ¯èþ² Væühsðüyæþ A¬MéÇ^óþ Vé°, A¿æýÅÇ® Æé‹Ðèþ ÐðþËç³Ë °ÐèþíÜçÜ¢¯èþ²rÏÆÿ¯èþ^ø ÐóþhÉõÜtr^óþ ÆæÿÖ§æþ «æþ–
Ðèþç³Ææÿ^èþÐèþÌñý¯èþ.
Note:-
The receipt should be certified by a Gazetted Officer of Andhra Pradesh Government in Service or by a
Magistrate if the applicant is residing outside the State.
