RUSHABH INFOSOFT LTD.

FORM C
[See sub-paragraphs (1) and (3) of paragraph 9]
STATE BANK OF
Application form for withdrawals under the Public Provident Fund
Scheme,1968
To
The Agent/Manager,
State Bank of
1. I wish to withdraw from Public Provident Fund Account No.
__10258244473________ a sum of Rs.Sixty seven Thousand Four
Hundred and Eighty Six and Paise Thirty Six __only________
(Rupees _67,486.36 /-_________). A period of
___15_______years has expired from the end of the year in which
the initial subscription was made.
1A. I have not made any withdrawal in the current year.

2. Certified, that the amount sought to be withdrawn

is required for the use of ____N/A______who is
alive and is still a minor.
3. The Pass Book is enclosed.(
Date : 24.05.2011
Signature or thumb impression of subscriber/guardian

(R.Somasundaram)
Score out whichever is not applicable
TO BE USED BY THE ACCOUNTS OFFICE
A/c No.
Date of initial subscription
Amount available in the Public Provident Fund Account
Amount available for withdrawal in accordance with para 9(1)/9(3)
of the scheme
Withdrawal of a sum of Rs. __________ sanctioned
Signature of Accounts Officer
Date
Received a sum of Rs. _67486.36_________ (Rupees Sixty Seven
Thousands and Four Hundreds and Eighty Six and Paise
36_______) by way of withdrawal from Public Provident Fund
Account No.
STAMP
Date
Signature/thumb impression of subscriber/guardian X (On Stamp
With Date)