Date :-

To,
The Trustees
ICICI Bank Ltd. Provident Fund
ICICI Bank Ltd,
Payroll Department
Trans Trade Centre,
5th Floor, Near Floral Deck Plaza,
Near Seepz, MIDC Andheri (E),
Mumbai 400 093.
Dear Sir,
Sub : Provident Fund Settlement
As I have resigned from the services of the Bank and not taken up any employment. I
hereby request you to settle my PF dues at the earliest.
I authorise you to deduct Income Tax, if any, payable on such withdrawal.
Thanking you,
Yours faithfully,
________________
( Signature )
Name :___________________________________________
Emp. No. :_____________ Date of Joining : _______________
Last Working Date : _______________________________
Address :__________________________________________
__________________________________________
__________________________________________
__________________________________________
Email ID. : ________________________________________
P.A.N. (Income Tax) : ______________________________
Tel. No. : _________________________________________
ICICI Bank SB A/c No. :_____________________________
continue.................

For Bank Account with other than ICICI Bank; Following

details are required for payment through NEFT
(1) Beneficiary Name : _________________________________
(Name of the account holder )
(2) Bank Account Number : _____________________________
(3) Name of the Bank : _________________________________
(4) Bank Branch location& address (Location along with City
name) : ___________________________________________
___________________________________________________
___________________________________________________
(5) NEFT / IFSC Code ( As mentioned on bank Cheque leaf)
:__________________________________________________
________________
( Signature )
To be submitted along with this form. Mandatory
(1) Copy of PAN card
(2) Cancel cheque of Bank Account mentioned above

Note : Incase of closure of Bank Account with ICICI Bank, payment

Will be done through NEFT.

continue.................

ADVANCE STAMPED RECEIPT

Received

with thanks

_______________________

from ICICI Bank Ltd. Provident Fund a sum of Rs.

(

Rupees

___________________________

___________________________________________) vide Cheque No./Fund Transfer/ NEFT

_____________ dated ___________________ towards full and final settlement of all my
Provident Fund dues.

Rs. 1/Revenue
Stamp
_______________
( Signature )
Name :___________________________

Note : Kindly affix Re. 1/-Revenue stamp, sign across and send
the advance stamped receipt along with the form.