FORM 19

RELIANCE INFOCOMM LIMITED EMPLOYEES PROVIDENT FUND

[Under Rule 22]
4TH FLOOR, NORTH WING, RELIANCE CENTRE, NEAR PRABHAT COLONY, SANTACRUZ,
MUMBAI - 55
(FORM FOR WITHDRAWAL OF PROVIDENT FUND ACCUMULATION)
To,
THE TRUSTEES,
RELIANCE INFOCOMM LIMITED EMPLOYEES PROVIDENT FUND

I hereby request you to pay me the amount standing to the credit of my provident fund account by mode of
remittance mentioned in col. 10.

1. Full Name (BLOCK LETTERS) ___________________________________________________________

*Father’s / Husband’s Name: ___________________________________________________________
*Complete Postal Address: ____________________________________________________________
__________________________________________________________
*Mobile /Telephone no. _________________________ Pin code ________________
2. Employee No. ______________ *E-Mail ID _____________________________Department__________

3. P.F. Account No. MH/ 46459 /________

4. Date of Joining Service :

5. Date of Leaving Service :

6. *Date of Birth :

7. Reason for Leaving

Service terminated on account of a) ill health of member b ) contraction c) discontinuation of
employer’s business or d ) other cause beyond the control of the member…………………………….
…………………………………………………………………………………………………………………….
Personal Reasons : Resigned / Migration / Superannuation / Retirement

8. Permanent Account Number ( PAN ) : …………………………

9. Date of leaving India :

(i) In case of migration or for permanent settlement abroad under Rule 22(c)

10. The remittance may be made by mode as under

(1) Postal Money Order at my cost ( only if the amount is less than Rs. 2500/-)
(2) Send cheque directly to my bankers. S.B. A/c No.______________________________________

Name and address of bank ________________________________________________________

_____________________________________________________ Pin Code __________________

(3) Through E- Net – Enclose original Cancelled Cheque

 DECLARATION OF NON EMPLOYMENT

I declare that I have not been employed in any factory/establishment to which the EPF Act applies for a
continuous period of not less than two months immediately preceding the date of my application for final
withdrawal of my Provident Fund money.

I certify that the particulars given above are true to the best of my knowledge.

Date ________________ Signature or left/right hand thumb

impression of the member

Certified that the above declaration has been signed/thumb impressed before me by Shri. / Smt.
__________________________________________ lastly employed in Reliance Infocomm Ltd.

For RELIANCE INFOCOMM LIMITED

Signature :
Name :
Designation :
Rubber Stamp
Date : ________________ of the Company :

FOR USE OF PERSONNEL DEPARTMENT

Certified that Mr./Mrs/Ms. ______________________________________who joined the company on

____________ has left the company w.e.f. ______________ on account of his/her resignation/
termination of service. We further certify that there are no dues recoverable from him/her and his/her
resignation/termination of service was not on account of any misconduct and therefore we
recommend/do not recommend settlement of his/her Provident Fund Account.

For RELIANCE INFOCOMM LIMITED

( )
Date _______________ Personnel Dept.

ADVANCE STAMPED RECEIPT

Received a sum of Rs. _______________ (Rupees __________________________________________

_____________________________________________________________________________________)
from the trustees of RELIANCE INFOCOMM LIMITED
by cheque No. _________ dated: ______________ in full and final settlement of my provident Fund
account no MH/ 46459 /__________

Affix Re. 1/-

Revenue
Stamp & Sign
across it