CIPLA LIMITED EMPLOYEES PROVIDENT FUND

_____________________________________________________________________________________________

FORM FOR WITHDRAWAL OF PROVIDENT FUND ACCUMULATIONS

1.

Name of Member: ______________________________________________________________________

(In Block Letters)
FIRST NAME
FATHER / HUSBANDS NAME
SURNAME

2.

Name of Claimant : ______________________________________________________________________

(other than member) FIRST NAME
FATHER / HUSBANDS NAME
SURNAME

3.

Emp. No.

: _______________________

4. Location

: ___________________________

5.

PF Account No.

: _______________________

6. PAN No.

: ___________________________

7.

Date of Joining

: _______________________

8. *Date of Leaving Service: __________________

9.

Reason For Leaving Service: _______________________________________________________________

10.

Full Postal Address: _____________________________________________________________________

(in block letters)
_____________________________________________________________________
________________________Pin Code:

State:

11.

Contact details

: Cell Number: -

Phone Number:-

12.

Mode of Remittance: () put a Tick in the box against the one opted.
(

) (a) By account payee Cheque

To be sent at the address given against item no. 10

) (b) By account payee cheque to be

sent direct to Bank for credit to
my S.B. A/c. under intimation
to me.
( Advance Stamped Receipt
Furnished below ).

Bank Details:
S.B. Account No.____________________________
Name of the Bank ________________________________
_______________________________________________
Branch ________________________________________
Full address of the bank____________________________
_______________________________________________

Certified that the particulars are true to the best of my knowledge.

The applicant has signed / thumb impressed before me.
X
For CIPLA LIMITED
EMPLOYEES PROVIDENT FUND
Trustee

Signature of the member / claimant

Trustee

Date :
DECLARATION OF NON - EMPLOYMENT

I declare that I have not been employed in any factory / establishment to which the EPF & MP Act, 1952 applies for a
continuous period not less than 2 months immediately preceding the date of my application for final withdrawal of my
Provident Fund money.
X
Date: __________________
Signature of the member
________________________
ADVANCE STAMP RECEIPT
Received a sum of Rs. _____________ (Rupees _____________________________________________________)
from CIPLA LIMITED EMPLOYEES PROVIDENT FUND towards the settlement of my provident fund
account.
Cheque No. _______________

Date: _____________
X

Re. 1.00
Revenue
Stamp

Signature of the member / claimant

(For office use only)
Account settled in Part / Full

Entered in Withdrawal Register

Initials

Enclosures:
a.
b.
c.
d.
e.
f.

Form 16 (If membership is less than 5 years for all the earlier years)
Visa Copy (In case of going abroad)
Death Certificate (In case of death)
Doctor Certificate (In case of medical unfitness)
Final Settlement Computation Sheet
Any other document (Please specify)

Note: * In case of death please write date of death