Wipro In Pf Settle Form 6i564k

(Form 19) (Please print all pages)

APPLICATION FORM FOR WITHDRAWAL OF ACCUMULATION FROM PROVIDENT FUND The Chairman Board of Trustees WIPRO SYSTEMS PROVIDENT FUND TRUST D Block, Sarjapur Road, Dodda Kannelli Bangalore – 560 035, Karnataka Sir, I hereby request you to pay the full amount standing to my credit in the Fund after making such deducion as may be authorised under your Provident Fund Rule Nos.22 and 23 1.

Name (in block letters): Sri / Smt

2.

Employee Number

:

3.

Number

: KN/11394/

4.

Permanent Address (where you want the cheque to be sent)

:

5.

Name & address of the present employer

6.

If there is any Provident Fund Scheme under present employment

7.

Ground on which the request for withdrawal is made (please proved documentary proof)

:

8.

Date of leaving India in case of migrating abroad

:

9.

The payment may be made by M.O. at my cost / cheque / cash :

10.

Particulars of last subscription i.e. month and amount

Locn :

Divn :

:

YES/NO

:

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.

Date

:

Signature of the member:

The member should state whether he : a. is retiring from service in the industry attaining the age of superannuation b. is retiring on of permanent and total incapability for work in any industry due to bodily or mental infirmity c. is migrating from India on permanent settlement abroad 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 …2/-

Wipro Technologies, HRD Ver HR 1.0 Jan 2000

Company Confidential

Page 1

If the claim for withdrawal is made on grounds mention in footnote (b) above, the certificate by a ed medical practitioner or the medical officer of the establishment should be enclosed. If the claim for withdrawal is made on grounds mentioned in (d) above, a certificate from such authority as may be specified, of non-employment for a period of sixty days in any establishment to which the scheme applies, should be encloses. If the claim for withdrawal is made on grounds mentioned in (c), the member should produce copies of port, visa and flight details. CERTIFICATE This is to certify that Sri / Smt _________________________________________________________ has signed before me the application for withdrawal of Provident Fund money. He / she is not employed in any establishment where there is provision for Provident Fund under Employee’s Provident Fund Act, 1952.

Date

:

Name :

Authorised Signatory

Address:

Designation & Seal Persons authorised to attest the application : 1. 2. 3. 4. 5. 6. 7. 8.

Gazetted Officer Post Master or Sub Post Master President of the Village Union President of the Village Panchayat Chairman / Secretary of the Municipal / District Local Board Village Munsiff MLA Member of Municipalities and Municipal Corporation

Wipro Technologies, HRD Ver HR 1.0 Jan 2000

Company Confidential

Page 2