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FOR SSC USE ONLY

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Request No. 21R052003732
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Mobile No. 9920975452

PS No. 20043950

Application for Provident Fund Withdrawal

To,
The Board of Trustees, LARSEN & TOUBRO OFFICERS AND SUPERVISORY STAFF PROVIDENT FUND, Shared services
Centre (Retirement Benefit Section),4th Floor, Krislon house, Off Saki Vihar Road,Saki Naka, Andheri (East),Mumbai
– 400072
1 PS No. & Name 20043950 - ARJUNSINH MANVAR
2 Date of Joining / PF Membership 13-JUL-2012 / 13-JUL-2012
3 No. of years’ service (Total PF membership) 7 Year / 10 Month / 23 Day
4 Entity / Unit LARSEN & TOUBRO LIMITED / HEIC
5 Cadre / Location COVENANTED M I - B / RANOLI
6 Purpose of Withdrawal PURCHASE OF HOUSE/FLAT (SELF OR JOINTLY WITH
SPOUSE)
7 PF wages ₹ 22,130.00
8 Applied Amount ₹ 399,100.00
9 Payment Mode NEFT
10 Bank Details
Bank Account No./IFSC 50100338237441/HDFC0009523
Bank Name HDFC BANK
Branch HDFC BANK - (SAMA ROAD)
11 Purpose Details
House/Flat Purchase
Owned by Jointly with Spouse
Address of House/Flat (To be B703, Sky Marc, Opposite Narayan Greens, Vamali,
purchased/constructed) Sama Savli Road, Vadodara, Gujarat 390008
Total Cost 3190000
ü     I certify that the above given particulars are true to the best of my knowledge.
Declaration
ü In case amount is used for any purpose other than PURCHASE OF HOUSE/FLAT (SELF OR JOINTLY
WITH SPOUSE) , I am liable to return the entire amount with penal interest.

Place :

Date : 4 Jun 2020