@ (APPLICABLE TO OFFICERS, SUPERVISORY STAFF & TRAINEES ) DATE OF RECEIPT. APPLICATION FOR WITHDRAWAL OF PROVIDENT FUND ACCUMULATIONS The Trustees, Larsen & Toubro Officers & Supervisory Staff Provident Fund Mumbai 400 072 Dear Si, SUB : SETTLEMENT OF PROVIDENT FUND DUES PART-A ja | NAME OF THE MEMBER 1b | NAME OF THE APPLICANT. (in case of OEATH of the member) (Lic [RELATIONSHIP WITH THE MEMBER. ‘COMPLETE POSTAL ADDRESS FOR COMMUNICATION PINCODE : TEL.NO.: E-MAIL 3. | NAME OF THE OFFICE /WORKS/ UNIT IN WHICH THE MEMBER LAST EMPLOYED. 4a] PS. No. OF THE MEMBER (as a confirmed employee) ab | P. S.No. OF THE MEMBER AS A GET (ifany) 4c | B.S. No. AS A CASUAL / TEMPORARY WORKMAN if any) 5a | DATE OF JOINING COMPANY 5b | DATE OF JOINING P. F. IN PREVIOUS EMPLOYMENT (in case PF Transfer received / applied tor) © | DESIGNATION / CADRE 7 | DEPT. NAME & CODE T DATE OF LEAVING COMPANY © | CAUSE OF LEAVING “RETIREMENT / RESIGNATION / SEPARATION (Strike out whichever is not applicable (TERMINATION / DISMISSAL / VRS Please specify the exact cause of leaving DEATH, mall other cases) ENCLOSURE (Please see page 2 footnote)10 1a) 1 declare that | am unemployed for more than two months b)* | am proceeding abroad (Passport / VISA Tickets) ¢)* Service Terminated on Medical grounds (Certificate from Co, Medical Officer) | 4d)" | have started own business (Partnership Deed / Factory Licence / Sales Tax registration / Shop & Est, Registration) * Attach necessary Documents O00? 11. |MODE OF REMITTANCE : (Please tick the relevant ) (Bank Details mandatory to be filled in) ‘a, Cheque tobe b. Chequetobe | ¢. CreditAdviceto a collected by the send by POST be raised on the Applicant personally at the address Accounting Centre from PAC mentioned for from which last communication pay was drawn ‘Saving Bank Account No | Name of the Bank Name & Address of the Branch Th ease of claim by nominee Date Place ‘Stamp / Signature of Bank Manager Signature of the Applicant PART-B. AUTHORISATION TO THE TRUSTEES | the applicant above named, do hereby authorise the trustees of LARSEN & TOUBRO LIMITED PROVIDENT FUND of +1952 te deduct and pay on my behalf to the company andlor to the LTKSPM all such amounts as are due and payable by me tothe company andior to the LTKSPM towards the full and final settlement of all my accounts with them Date Place Signature of the Applicant PART -C ADVANCE STAMPED RECEIPT Received from the trutees of LARSEN & TOUBRO LIMITED PROVIDENT FUND of 1952 2 sum of Rs towards the full & final settlement of the Provident Fund Account as mentioned above Affix Rs Revenue Stamp, Date Signature or Left / Right thum® Place impression of the member / nominee FOOT NOTE “The copy of the respective documents as mentioned hereunder should be attached alongwith the application ‘VRS! Separation / Retirement / Resignation Acceptance letter Termination Termination letter Dismissal - Dismissal letter Death Death certificate, Affidavit & Indemnity Bond (When the nomination is not in favour of the applicant) Others Documentary proof substanting the reason of leavingFORM NO PF. -V DETAILS FOR SETTLEMENT OF PF. DUES OF THE EX-EMPLOYEE (TO BE FILLED IN BY THE RESPECTIVE ACCOUNTS DEPARTMENT) 1. CONTRIBUTION FOR THE PRECEDING SIX MONTHS, YEAR pr [MEMBER'S] vPF | COMPANY'S} EPS REF LOAN] INTO 20_.__| BASED PF PF INSTALMT | REF LOAN MONTH | SALARY / RECOVERY| WAGES TAN FEB MAR APR. MAY. SUN, JUL, AUG. ‘SEP ‘ocr, NOV. DEC DETAILS OF TAX DEDUCTED AT SOURCE FROM INCOME CHARGEABLE UNDER THE HEAD " SALARIE! As per FORM NO. 16 { Under IT Rule 31 (1) (a) } (TO BE FURNISHED ONLY IF THE TOTAL SERVICE IS LESS THAN 5 YEARS) DETAILS /FY : : : = - Gross Salary ‘Standard Deduction Profession Tax Gross Income ‘Add/Less_ other Income (Housing) Total Income Deduction under chapter VI-A US BOGCC/B0D/80DD/80DDB/80U “Total Taxable Income. Tax on Total Income Rebate under Chapter Vill U/S 88 A) Total Investment Amount (Excluding PF) US 88) Rebate on A. B)_Rebate U/S 88B/88C/80 (G)_Total Rebate ‘Total Tax Payable/Paid (Inclusive of Surcharge) Employer's share of PF Contributior| Interest on Employee's Contribution Interest on Employee's Contnbution *To be filed by RBS/ PACDate FORM NO. PF - V (contd.) LAST DATE UPTO WHICH THE WAGES / SALARY HAS BEEN PAID LAST MONTH IN WHICH RECOVERY TOWARDS PF REFUNDABLE LOAN INSTALMENT & INTEREST WAS MADE (Applicable if no recovery was made as above in preceding six months.) OTHER RECOVERIES (In case of Powai based employees only) a. Credit Society Dues (LTKSPM) =... b. Salary Dues a ©. Other Dues (if any) oes (Authorised Signatory) NAME Unit Name INSTRUCTION TO THE ACCOUNTS DEPT. Please ensure that the application is made in the prescribed form only and all the relevant documents as per the Application Form are enclosed Please ensure that the Monthly PF Recovery details are furnished upto and including the Date of Leaving Please ensure that all the relevant details as per Application Form as well as Form No PF-V have been filed in. In case of non applicability of the any details, please write “Not Applicable in the space provided for. Incomplete Form in any respect shall be rejected. {F the Application preferred by the nominee(s) of the deceased employee, please erisure that the Signature / Thumb impression of the Applicant(s) is attested by the concerned Welfare Dept./Regional Personnel Dept Amount consists of payments to certain pension funds (BOCCC), Medical Insurance Premia (80D), Medical treatment Maintenance expenses for handicapped dependant (800D) / (8000) Medical expenses on specified disease / ailments (80DDB), Donations to certain funds /charitios (806), Income for services rendered outside India (8ORRA), Deduction for permanent phycica disability (80U) allowed to be considered for TDS Amount consists of PF/VPF Contribution, LIC/ULIP premium & Retirement Benefit Plan of UTI CTD & PPF, NSC & accrued interest, Repayment of housing loan, Deposit in National Housing Bank, National Savings Scheme, Equity Linked Saving Scheme, Approved Units! Issues ot Public companies for infrastructure & power sectors. (for Rebates & Relief under section 82)