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FORM NO. 19

APPLICATION FORM FOR WITHDRAWAL OF ACCUMULATION

FROM PROVIDENT FUND

PurposeTo withr!w the !""u#u$!te %u& !%ter resi'&!tio& %ro# Wipro Lt

Pro"ess

I& "!se e()e#p$o*ees w!&t to withr!w the PF+ the* h!,e to %i$$ up For# 19 !& 'et it

!tteste -* !/ette o%%i"er !& se& it to A#!$&er Trust.0e%ore the* re$e!se PF+ A#!$&er Trust wi$$ 'et "o&%ir#!tio& %or# us whether !&* ues

!re outst!&i&'.

Aress to -e se&t to

Att& Mr. Rohit 2u#!r3Mr. 4u&i$ 4heeThe Ch!ir#!& 3 0o!r o% Trustees+WIPRO Li#ite E#p$o*ees5 Pro,ie&t Fu&+AMALNER 6Distt 7!$'!o&8

STD Code No. 02587222453

Fax. No. (02587)

222985

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FORM NO. 19APPLICATION FORM FOR WITHDRAWAL OF ACCUMULATION

FROM PROVIDENT FUND

To,The Chairman / Board of Trustees, Date of Joining: __________________

WIPROLi#ite E#p$o*ees5 Pro,ie&t Fu&,

AMALNER 6Dist 7!$'!o&8 Date of Leaving: __________________

Ihereby request you to pay me the full amount standing to my redit in the fund after ma!ing suhdedution as may be authorised under your "rovident #und $ule %os& '' ( ')&

*+ %ame -.n blo! letters 0 1hri& /1mt& _________________________________

*' "resent full address 0___________________________________________0___________________________________________0___________________________________________0 "in Code_______________

*) "rovident #und 2ount %o& 0 34/567/___________________________________0 8mployee %o& ______________________________0 Division ___________________________________

*6 %ame and address of the 0___________________________________________

present employer& 0___________________________________________ 0___________________________________________0___________________________________________

*9 .f there is any "rovident #und 0 1heme under present 0 81 / %; -.f %;, please send ertifiate&

8mployment< 0

*= >round on ?hih the request for 0___________________________________________?ithdra?al is made < 0___________________________________________-"lease give reason for ?ithdra?al 0___________________________________________

*@ Date of leaving .ndia in ase 0___________________________________________migrating a broad& 0-"lease attah Aero opy of 0passport visa et& 0

*7 The payment may be made by 0___________________________________________D&D& at my ost / Cheque payable 0___________________________________________at station -"lease give name of 0___________________________________________to?n -1B. Code %o& 0___________________________________________

*5 "artiulars of last subsription 0___________________________________________i& e& month and amount& 0___________________________________________

I ertify that the partiulars given above are true to the best of my !no?ledge& Ihereby pledge toindemnity you against any laim for .nome Ta that may arise in future in this onnetion&

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Date: / / 4i'&!ture or $e%t 6%or #!$e8+ ri'ht 6%or %e#!$e8 h!&thu#- i#pressio& o% the #e#-er.

'

The member should state ?hether he -a is retiring from servie in the industry after attainingthe age of superannuation -b is retiring on aount of permanent and total in apability for ?or! inany industry due to badly of mental infirmity - is migrating from .ndia for permanent settlementabroad, -d has not been employed in fatory to ?hih the sheme applied for a ontinuous period ofnot less than t?o months immediately preeding the date of appliation&

If the laim for ?ithdra?al in made on grounds mentioned in foot note -b above, a ertifiatebe a registered 3edial "ratitioner ;ffier or the 3edial ;ffier of the fatory should be enlosed ifthe laim for ?ithdra?al is made on grounds mentioned in -d above a ertifiate from suh authorityas may be speified of nonemployment for a period of t?o months if any fatory to ?hih the shemeapplies, should be enlosed, if the laim for ?ithdra?al in made on ground mentioned in -8 themember should give details regarding "assport %o&, Eisa %o&, #light %o& et&

CERTIFICATE

This is to ertify that 1hri / 1mt& _____________________________________ hassigned before me the appliation for ?ithdra?al of "rovident #und money& 4e / 1he is notemployed in any fatory of organisation ?here is any provision for "rovident #und under8mployees "rovident #und 2t, +59'&

Date: / /

%ame:

2ddress:

1ignature of attestee

Designation and 1eal

F&F&F&F&F&F&F&F&F&F&F&FF&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&F&FN!#e o% perso& !uthorise to the !pp$i"!tio&.

*+ >aGetted ;ffier *' "ost 3aster of 1ub "ostmaster*) "resident of the Eillage Hnion*6 "resident of Eillage "anhayat*9 Chairman / 1eretary of 3uniipal / Distrit Loal Board&*= Eillage 3unsif *@ 3&L&2&

*7 3ember of Borough 3uniipalities and 3uniipal Corporation&

#ile: pfms?#;$3+I"# -!d

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