Provident Fund Withdrawal Form

The Trustees, Dated: 04/05/2015

HDFC Bank Limited Covered Employees Provident Fund Trust
Finance – PAD, Lodha - I Think Techno Campus, Building - Alpha, 8th Floor, Details updated in blue color are
Next to Kanjur Marg Railway station (E), Mumbai - 400042. mandatory to be filled by
employee
Dear Sir,
I hereby request you to settle my PF Accumulation and credit the same into my HDFC Bank Salary
Saving Bank A/c after making deductions as may be authorized under the Income Tax Act 1961.
Name of Member Rohan S. Rai
Father’s / Spouse Name Sudesh R. Rai
Employee Code No. R12345 PF A/c No. R12345X
Date of Birth 18/12/1981 Date of Joining 02/03/2008
Date of Leaving 11/08/2014 Reason of Leaving Resigned
PAN No. (10 Digit) ALOPS1441D Mobile No. 9999990001
A - 401 Adarsh CHS, Azad Nagar, Kanjurmarg - Provide
42 your
Member Address personal email id
only & NOT your
Email id ( Personal ) Rohan.pai1985144@gmail.com HDFC Bank
official ID.
I declare that I have not been employed in any factory or other establishment to which the
Employees’ Provident Funds and Miscellaneous Provisions Act, 1952 applies for a continuous period
of not less than 2 months immediately preceding the date of my application for final withdrawal of
my provident fund money.

 Please note PF settlement will be credited to members HDFC Bank’s salary account
by default.
 In case your salary account is closed, kindly provide alternate bank account details along
with a copy of cancelled cheque.
Beneficiary Name
Only if HDFC Bank
Bank Name Salary a/c is closed then
Bank Account No IFSC Code provide alternate bank
a/c details for NEFT

 There is tax levied in case your membership is less than 5 years. Membership with previous
employer will be considered only if the same has been transferred to HDFC BANK Ltd Covered
Employees Provident Fund Trust. Please note that as per the provisions contained in the
Provident Fund Act, it is advisable to transfer the PF accumulations to your current employer.
In case you wish to withdraw, the same will be settled after a break of 60 days from the date
of separation please.

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

(SIGNATURE OF MEMBER)
Advance Stamped Receipt
Received with thanks form HDFC Bank Ltd Covered EPF Trust a sum of Rs. ____________ (Rupees
-----------------------------------) vide Cheque No. / Fund Transfer/ NEFT _______dated _______ towards
full & Final Settlement of all my Provident Fund dues.

Keep receipt amount, Cheque No, date Fix Revenue Affix Re. 1
field Blank. Stamp and Sign Revenue
across same Stamp

(SIGNATURE OF MEMBER)