B™.Éç³.Éç³.i.Á.ÔéQ ¯ðþ™.

41
DIR. OF INS. NO. 41
B™É«æþÉ糧óþԏý É糿æý€èþÓ ÁÐèþ’ yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ
GOVERNMENT OF A.P. DIRECTORATE OF INSURANCE

ɴ뙡Äèÿ ÁÐèþ’ yìþ³ç “Åsìü yðþƔ ÿð MæüÆt ÿæ  MéÆéÅËÄèÿÐèþ. ..............

OFFICE OF THE REGIONAL DEPUTY DIRECTOR OF INSURANCE ............
º}ýÐèþ MöÆæÿN §æþÆæÿRêçܐ¢
Application for Loan
(çܒ^èþ¯èþË MöÆæÿN Éí³µ ^èþ’yæþyæþ)
(For instructions, Please see overleaf)
1. ^èþ™§é §éÆæÿ° õ³Ææÿ €èþ™Éyìþ õ³Ææÿ çßø§é
Name, father's name and the designation of the subscriber ________________________________
2. A€èþyæþ ç³°^óþçܐ¢¯èþ² MéÆéÅËÄèÿÐèþ õ³Ææÿ
The name of the office where he is employed ________________________________
3. ^èþ™§é §éÆæÿ ¯ðþ™ºÆæÿ ÌôýMæü ´ëËïÜ ¯ðþ™ºÆæÿ
Subscriber No. or Policy No. ________________________________
4. §æþÆæÿRêçܐ¢Ìø Møǯèþ Ææÿ’´ëÄèÿË Ððþ€èþ¢Ðèþ
The amount of the loan applied for ________________________________
5. º}ýÐèþ §óþ°MöÆæÿN AÐèþÜç ÆæÿÐèþ (Ððþ¯èþMæü VæüË Üç ’^èþ¯èþ˯èþ
§æþ–íÙtÌø Äèÿ™^èþMö° §æþÆæÿRêçܐ¢Ìø ÌôýMæü ©°€ø
糙糑 ÌôýQÌø ÑÐèþÆæÿÐèþË¯èþ €ñþːç³ÐèþÌñý¯èþ).
The object or objects for which the loan
is required (full particulars may please begiven
in the covering letter or application keeping in
view the instructions printed overleaf) ________________________________
6. º}ýÐèþ ÇW H°² ÐéÆÿ§éËÌø ^ðþÍϙ^èþ §æþË^èþMö¯é²Ææÿ
The number of instalments in which the loan is
proposed to be repaid. (Not exceeding 48
according to Rules 46) ________________________________
7. ^èþ™§é §éÆæÿ ´÷™§óþ Ððþ€èþ¢Ðèþ ¯ðþËçÜÇ i€èþÐèþ
Total monthly emoluments drawn by the subscriber ________________________________
8. Ðóþ€èþ¯èþÐèþ ¯èþ™yìþ €èþWY™ç³‘ː
Deductions from pay ________________________________
(G) B.Éç³.Éç³.i.Á. ÔéQ Éï³ÑÄèÿÐèþ
A.P.G.L.I. Dept. Premum ________________________________
(¼) B™.Éç³.Éç³.i.Á.ÔéQ º}ýÐèþ ÐéÆÿ§é
A.P.L.I.D. Loan instalment ________________________________
(íÜ) H§æþÆÿ¯é C€èþÆæÿ çÜçßMéÆæÿ çܙZÐèþ ÌôýMæü çܙZÐèþË ÐéÆÿ§é Ððþ€èþ¢™
Instalments of any other Co-operative Society a Societies ________________________________
(yìþ) »êřN º}ýÐèþ
Bank Loans ________________________________
(C) É糿æý€èþÓÐèþ Ðèþ™lÆæÿ ^óþíܯèþ Ððþ’sêÆæÿ MéÆæÿ º}ýÐèþ ÌôýMæü Væü–çß °ÆéÃ}ýÐèþË
Motor Car Loan or House Building Loan sanctioned by Government ________________________________
(GŽ·) B§éÄèÿç³‘ 糯èþ²
Income Tax ________________________________
(h) HÐèþÆÿ¯é C€èþÆæÿ €èþWY™ç³‘ː
Any other deductions ________________________________
Ððþ€èþ¢Ðèþ
Total ________________________________
9. º}ýÐèþ ^ðþÍϙ^èþ MøÆæÿ ÉsóüfÈ ÌôýMæü õÜtr »êřN É»ê™_ õ³Ææÿ
The name of the Treasury or branch of the State Bank
where the payment of loan is desired. ________________________________
10. _Ææÿ¯éÐèþ’
Address ________________________________
 ò³”¯èþ €ñþÍí³¯èþ ÑÐèþÆæÿÐèþË, f€èþ ç³Ææÿ^èþºyìþ¯èþ §æþÆæÿRêçܐ¢Ìø €ñþÍí³¯èþ ÑçÙÄèÿÐèþË çÜÇÄðÿ”¯èþÐèþ°Äèÿ ò³” €ñþÍí³¯èþ AÐèþçÜÆæÿÐèþ ÌôýMæü A¯èþÐèþçÜÆæÿÐèþË
°Ñ€èþ¢Ðèþ Ðèþ’É€èþÐóþ ò³”MæüÐèþ¯èþ QÆæÿa ^óþÄèÿVæü˯èþ°Äèÿ C™§æþ Ðèþ’ËÐèþ¯èþ Éç³Mæüsìü™^èþ^èþ¯é²¯èþ. ÔéQ °ÄèÿÐèþ’Ðèþã ¯èþ¯èþçÜǙ_ B™É«æþÉ糧óþԏý É糿æý€èþÓ
ÁÐèþ’ ÔéQ MéÆæÿŧæþÇØMìü °Ææÿ~Æÿ™^èþ 糧æþ®€èþË¯èþ, Ðóþ€èþ¯èþÐèþ ¯èþ™_ º}ýÐèþ, Ðèþyìþz €èþXY™ç³‘˯èþ ^óþÄèÿ E€èþ¢ÆæÿÓː gêÈ ^óþÄèÿrN C™§æþ Ðèþ’ËÐèþVé
ÐéÇMìü A¬MéÆæÿÐèþ C^èþa^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¨ : §æþÆæÿRêçܐ¢ §éÆæÿ çܙ€èþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ ÐèþÉ§æþ

Date ....... 197 Signature of Thumb Impression of the applicant

ò³” §æþÆæÿRêçܐ¢Ìø €ñþÍí³¯èþ ÑÐèþÆæÿÐèþË ¯éN €ñþÍíܯèþ™€èþ ÐóþÆæÿN ¯óþ¯èþ ÑÔèýÓíܙ^èþ¯èþ™€èþ ÐèþÆæÿN Äèÿ§éÆæÿ¦ÐèþË°Äèÿ, ò³” çܙ€èþMæüÐèþ ÌôýMæü »ör¯èþ
ÉÐóþÍ ÐèþÉ§æþ ...................................................... VéÇ §æþ°Äèÿ C™§æþ Ðèþ’ËÐèþVé «æþ–ÒMæüǙ^èþyæþÐðþ”¯èþ¨. BÄèÿ¯èþ B™.Éç³.Éç³.i.Á.
ÔéQ ¯èþ™yìþ Ææÿ’. .................................... º}ýÐèþ ¡çܐMö° Äèÿ¯é²Ææÿ. C™§æþË C™Mæü¯èþ’ Ææÿ’. ....................................
ː »êMîü Äèÿ¯é²Ææÿ.
It is hereby certified that the particulars stated in the above application are correct to the best of my knowl-
edge 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 out-
standing.

«æþ–ÒMæüǙ^èþ Vóühsðütyþ A¬MéÇ çܙ€èþMæüÐèþ

Signature of the
certifying Gazetted Officer ___________________

€ôþ¨: «æþ–ÒMæüǙ^èþ A¬MéÇ õ³Ææÿ

Date ... 197 Name of the certifying Officer _________________

MéÆéÅËÄèÿÐèþ ÐèþÉ§æþ çßø§é

Office Seal Designation _______________________________

VæüÐèþ°Mæü:& §æþÆæÿRêçܐ¢ §éÆæÿ C¨ÐèþÆæÿMóü ÁÐèþ’ ÔéQ ¯èþ™yìþ º}ýÐèþ ¡çܐN¯èþ² ÄðÿyæþË ò³” «æþ–Ðèþ ç³É€èþÐèþò³” §æþÆæÿRêçܐ¢ §éÆæÿ°, AÐèþÅÐèþí߀èþ E¯èþ²€ø§øÅW
çܙ€èþMæüÐèþ ^óþÄèÿÐèþÌñý¯èþ.
Note:- In case the applicant has already obtained loan from Insurance the above certificate should be signed by
the applicant's immediate superior.
 糨 ò³”çÜË Ýët™ç³‘
Stamp 20 P. B™.Éç³.Éç³.Á.Mé.{îþ.¯ðþ™.40
DIR. OF INS. F. NO.40

ÆæÿÖ§æþ
RECEIPT
VæüÐèþ°Mæü:& Ððþ€èþ¢Ðèþ Ææÿ’. 20 ËN ѐ™_¯èþ GyæþË Ýët™ç³‘ A™sìü™^èþÐèþÌñý¯èþ.
Note:- If the amount exceeds Rs. 20, this receipt should be duly stamped.

×/×Ðèþ ...................................................................... VéÇ ÁÐèþ’ / É´ëÑyðþ™r 緙yæþ/º}ýÐèþ/

»ø¯èþçܐ Ððþ€èþ¢Ðèþ¯èþN çܙº™¨™_¯èþ ^èþ™§é§éÆæÿ ¯ðþ™ºÆæÿ ................................... ÆæÿÖ§æþ .................................. AÆÿ¯èþ
¯ó þ ¯è þ  C™§æ þ Ðè þ ’ËÐè þ Vé B™É«æ þ Éç ³ §ó þ ԏ ý Éç ³ ¿æ ý €è þ Ó ÁÐè þ ’ MéÆéÅËÄè ÿ Ðè þ , ò ß ” § æ þ Æé»ê§æ þ  ¯è þ ™yì þ Ææ ÿ ’´ëÄè ÿ Ë (A™Mð ü ËÌø)
................................... (A„æþÆæÿÐèþËÌø) .................................................................. çÜÓÄèÿÐèþVé ×/
×Ðè þ  .................................................................. §éÓÆé
................................................................. €ôþ© VæüË .................................... ¯ðþ™ºÆæÿ ^ðþNP & »êřN
Éyé緑t §éÓÆé Ðèþsìüt¯èþrÏ €ñþÍÄèÿç³Ææÿ^èþ^èþ¯é²¯èþ.
Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of

Sri/Smt. .............................................................................. Subscriber No. ....................................................

I .............................................................................. hereby knowledge receipt of Rs. (in figures

......................................... ) (in words ........................................................................................................ ) From

the Directorate of Insurance, Hyderabad per self, Sri/Smt. ..............................................................................

Attorney/Bearer * per Cheque / B.D. No. ........................................ Dated ....................................... 19 .

¡çܐN¯èþ² ÐéÇ çܙ€èþMæüÐèþ ´ëËïܧéÆæÿ & MðüÏÆÿÐèþ§éÆæÿ ÄðÿMæüP çܙ€èþMæüÐèþ Ìôý§é »ör¯èþÉÐóþÍ ÐèþÉ§æþ
Signature of receipient Signature of thumb-Impression of the Policy holder/
Claiment.

[P.T.O.
 ¯é çÜÐèþ„æþÐèþÌø çܙ€èþMæüÐèþ ^óþíܯèþ ò³” çܙ€èþMæüÐèþ & ÐóþÍ ÐèþÉ§æþ ____________________________ ÐéÇ É«æþÒMæüÆæÿ}ýÐèþ
×/×Ðèþ ...................................................... 糑ÆæÿçÜPǙ^èþMö° ò³” ^ðþNP¯èþ çÜÓÄèÿÐèþVé A™§æþgôýÄèÿyæþÐðþ”¯èþ¨.
On the strength of certification of
¯óþ¯èþ C™§æþ Ðèþ’ËÐèþVé «æþ–Ðèþç³Ææÿ^èþ^èþ¯é²¯èþ.
______________________________________
I hereby certify that the above signature/thumb
_______________________________________________
impression is of Sri/Smt. ______________________ the above cheques reserved personally .
who has signed in my presence.

Væühsðüyæþ A¬MéÇ õ³Ææÿ

1. Name of the Gazetted Officer______________

___________________________________

___________________________________

çßø§é çܒç³Ç™sðü™yðþ™r çÜàÄèÿ çܙ^éËNyæþ, ÁÐèþ’

Superintendent Asst. Director of Insurance
2. Designation __________________________

«æþ–ÒMæüǙ_¯èþ €ôþ¨
3. Date of Attestation ______________________

MéÆéÅËÄèÿç³‘ ÐèþÉ§æþ
OFFICE SEAL
VæüÐèþÝë¢
Clerk

«æþ–ÒMæüǙ_¯èþ A¬MéÇ çܙ€èþMæüÐèþ

Signature of the Certifying
Gazetted Officer

VæüÐèþ°Mæü:& B™É«æþÉ糧óþԏý çÜÈÓçܐÌø Äèÿ¯èþ² Væühsðüyæþ A¬MéÇ^óþ Vé°, A¿æýÅÇ® Æé‹Ðèþ Ððþːç³Ë °ÐèþíÜçܐ¢¯èþ²rÏÆÿ¯èþ^ø ÐóþhÉõÜtr^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.