Form No 13

APPLICATION FOR LEAVE

(R1:1Ie 113, Part I)
(Note:-Items 1 to 16 must be filled in by all applicants wh~ther
Gazetted or Non-Gazetted)
l. Name of Applic ant •
: S·upY \~- SR
2. Date of Birth
: 01;;oiz ;/rq87
3. Post held
: Jurno r Vrojecl Asst.
4. Depart ment, Office and section
5. Pay and scale of Pay
: 1'}000 -4360 0
6. Date of entry in service
: 02/ o 4,/ 20 2..G
7. Date of commencement of
Continuous service
8. Whether the applica nt ha~ got
confirmation in any post, irso from
which date and in which post :
9. Addres s during leave : P RA- 2. ;bA ~ As hYo.mO\tt-1 Ri,I, Pun ru \,::.kajY!u~
°'
10. House rent allowance, Conveyance - A'rO\.W\tX.q l.P O) ~ l V \I\,\. - O3L
allowance or other compensatory
allowance drawn in the presen t post:
11. Nature and period of leave applied
and date from which require a : en, \J C..~te. ~°'9Ve , 2~ / b / 2025
12. Sunday s/holid ays, if any, propos ed ~;;J./ 08 /'-o 2 5
to be prefixe d/suffixed to leave : :
13. Groun d on which leave is applied for: Ch\\~ UAre. Le ot v·e.
14. Date of return from last leave and
nature and period of that leave ..
15. (a) I undert ake to refund the difference between the leave salary drawn
during commu ted and that admissible during half pay leave which
would not have been admissible in the evenl of my retirement from
service at the end of or during the currency: of leave.
(b) I undert ake to refund the feave salary arawn during 'leave not due'
which would not have been admissible had rule 85, Part I ,not been
applied in the event of my voluntary retirement or resignation from
service at any time until I earn half pay leave not less than the amount of
leave not due availed of by me.

16. Place: lv,Vo.V '\~Y\A rYl Signature of a 1cant

(with date) [P.T.OJ
17. Rcn,nl"k-s nnd or t'C('( \l\\l\\ l'ndn tlon of the contr ollin
g offic er.

Sign nturc (with date} and

dcsig nntio n.

Note:- In the case of n Gov crnn ,cnt scrvn nt who is mcnt

nlly unso und and or phys icall y
unab le to fill in the cohn nns of this form nnd sign it,
the guar dian of his
nppo inttu cnt unde r the lndin n Lunney Act,. 1912 (Ccn
tral Act IV of 1912) or any
pers on auth orise d by t
he colu nm and sign the applicntio11 for nnd on beha lf
of the Gov ernm ent serva nt.

Cert ifica te Rega rdin g Adn tissi bilit y of Leav e

(By Acco unt Gene ral in the case of Gaza tted officers)

18. 1
Cert ified tl.1at .... .... .... .... .... .... .... .... .
'
. .... .... .... .... .... .. .
(N"ature of lea, e) for . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
. . . .... .... .... .... . .
from . . . . . . . . . . . . . ..... .... to. . . . . . .... .... ....
.. .is admi ssibl e unde r
Rule . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . .. . . . . . .
. . . . . . . . . . . . . of Kerala
Serv ice Rule s."

Sign ature (with date)

Desi gnat ion.
19. *Ord ers of the sanc tioni ng auth ority :

Sign ature (with date)

Desi gnati on.
*If the appl ican t is draw ing any com pe~a t~ry allow
ance the sanc tioni ng auth ority shou ld
state whe ther on the expi ry of leave he 1s hkel y to
retur n to the same post or to anot her
post carry ing a simi lar allow ance .