. APPLICATION FOR WITHDRAWAL FROM GPF FUND / CPF 1. Name of the subscriber 2. Designation 3. Account No. 4.

Basic Pay 5. Date of joining in service and date of superannuation. : : :MIT/NIC/GPF/ :Rs : : FUND

6.

Balance at the credit of the subscriber on the date of application as given below:(i) Closing balance as per statement for the year 200 -200 Credit from to on account of monthly subscription form Refund made to the fund after closing balance vide (i) above. Withdrawal during the period from to Net balance at credit on date of application :Rs

:Rs

(ii)

:Rs

(iii)

:Rs

(iv)

:Rs

(v)

7. 8.

AMOUNT OF WITHDRAWAL REQUIRED (a) Purpose for the withdrawal is required (b) Rule under which the request is covered

9.

Whether any withdrawal was taken for the same purpose earlier. If so, indicate the amount and the year.

:Rs

10. Name of the account officer maintaining the Provident Fund Accounts

Signature of the applicant