Form 19 Application Form for withdrawal of accumulation from Provident Fund

The Trustees, Employee No: __________WIPRO SYSTEMS PROVIDENT FUND TRUSTEC1, Tower 4, 3rd Floor,72, Electronics City Location : Division:Keonics, Hosur Road, Bangalore – 560 100Phone – 39154389 / 90 / 91 / 92 Mail ID :

Sir, Contact No.

I hereby request you to pay the full amount standing to my credit in the Fund after making such deduction as may be authorized under your provident Fund Rule No. 22 and 23.

1. Name (in block letters): Sri / Smt

2. Father’s Name:

3. PF Account Number: KN/BN/11394/ Date of leaving Service: ___ / ___ / ___ DOB: ___ / ___ / ___

4. Name & address of the employer in which the Member was last employed: WIPRO LTD

5. Ground on which the request for withdrawal is made (Reason for leaving): Resigned /Abroad /Retirement

6. Mode of Payment: A/c Payee Cheque, S .B. A/c No. __________________________

Name of the Bank:_____________________________________________ PAN NO. _________________

7. Present Postal Address ( Where you want the cheque to be sent )____________________________________________

DECLARATION BY EX-EMPLOYEE

Certified that the particulars furnished by me are correct

I, _______________________declare that I have not been employed in any establishment/Factory to which the act applies for a continuous period not less than 2 month immediately preceding date of my application for final withdrawal of my Provident Fund money.

I certify that the particulars given above are true to the best of my knowledge; I hereby pledge to indemnify you against any claim for Income Tax that may arise in future in this connection

Witness: Signature of the Member

Name: ________________________________________

Address: ______________________________________________________________________________________

Contact No: __________________________________ Sign______________________________________

Note: Following proof are Mandatory, else application will be rejected

1) PAN CARD2) Original Cancelled cheque leaf:- Bank A/c should be same as your Wipro salary account. Else, it should be certified by your Bank

manager/Authorities along with cancelled cheque leaf3) Address proof a) Should match with Wipro Records b) If address does not match with Wipro records then we require documentary proof of the same

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AFFIX YOUR PHOTO

Certified that the particulars furnished by the above member are correct as per our records;

Signature of the Employer/HR Department With office seal

The member should state whether he/she:

a. Is retiring from service in the industry attaining the age of superannuation.

b. Is retiring on account of permanent and total incapability for work in any industry due to bodily or mental

infirmity, the following documents to be produced. & produce the certificate by a registered medical

practitioner or the medical officer of the establishment should be enclosed.

c. Migrating from India on permanent settlement abroad or for Job abroad or for higher studies abroad, the following documents to be produced:- copies of Passport, visa and air –ticket/offer letter/admission letter.

d. Has not been employed in an establishment to which the scheme applies for a continuous period of not less than sixty days immediately preceding the date of application.

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