Steps for filling Provident Withdrawal form

You are requested to clearly mention all the details from point no.1 to point no.11. Signature at the bottom of the page 1 PF will be credited only to ICICI Bank account .Kindly provide the cancel cheque incase of non salary ICICI Bank account . Signature on Page 2 below Declaration of Non Employment Signature of the employee on Page 2 .Fix the Re.1 revenue stamp and need to sign across. You need to attach the copy of Permanent Account Number (PAN) along with the form. It is mandatory as per the Income Tax, or else your form will be rejected .

Steps for filling Pension Withdrawal form Mention your Employee Code on top of the Pension Withdrawal Form You are requested to clearly mention all the details in BLOCK LETTERS from point no.1 to point no.3 Point no 4,5,6 leave it blank Point No.9, 10, & 12 Please leave it blank Point no.11 please mention the complete Bank branch address

It is Mandatory to attach ORIGINAL CANCELLED CHEQUE along with the Pension withdrawal form pertaining to any of the saving Bank account number mentioned on point no 11 or else the form will get rejected by the Regional Provident Fund Commissioner . Signature on bottom of the Page 2 where (X) is marked . Fix revenue stamp & signed across on Page 3 & keep all the details blank Page 4 please keep it blank Address for sending the PF and Pension withdrawal form ICICI Prudential Life Insurance Company Limited Shared Services PF Department Ground Floor, Vinod Silk Mills Compound, Ashok Nagar, Chakravarti Ashok Road, Kandivali (E), Mumbai -400101

ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. EMPLOYEES PROVIDENT FUND ICICI Prulife Towers, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai 400025
1. 2. 3. 4. 5 Name of the member (In block letter) Employee Code _______________________________________________________ ______________________________________________________

PROVIDENT FUND WITHDRAWAL FORM

Fathers Name (or husbands name ______________________________________________________ in the case of married women) PF Account No. (Same as Employee Code) Employee PAN No. (Mandatory) _____________________________________________________ _______________________________________________________ _______________________________________________________

6. Date of leaving service 7. 8. Reason for Leaving Service Full postal address (In block Letters)

RESIGNED
_______________________________________________________ _______________________________________________________ _______________________________________________________ PinCode:______________________State_____________________

9. Email ID (Personal) 10. Mobile No. 11. Mode of Remittance

_______________________________________________________ _______________________________________________________ ( ) put a TICK in the box against the one opted

a)

By account payee cheque to be sent At the address given against serial no. 8 ( ) (Name to be appeared on Cheque) (IN BLOCK LETTERS) _________________________________________________ S.B. Account No. _____________________________ Name of the Bank: - ICICI Bank Ltd

b) By credit to my (Advance stamped Receipt furnished below)

Branch ____________________________________________ Full address of the branch _____________________________ __________________________________________________

X Signature of the member Address for sending the form- ICICI Prudential Life Insurance Co. Ltd.- Shared Services-PF Department Gr. Floor, Vinod Silk Compound, Chakravarthy Ashok Road, Ashok Nagar ,Kandivali - East, Mumbai - 400 101

Certified that the particulars are true to the best of my knowledge Date of joining the establishment Date of Leaving Service : : _________________________________ _________________________________

The applicant has signed / thumb impressed before me. X Signature of the member ICICI PRUDENTIAL LIFE INSURANCE CO. LTD EMPLOYEES PROVIDENT FUND Trustees. Encl. DECLARATION OF NON-EMPLOYMENT I declare that I have not been employed in any factory / establishment to which the EPF & MP Act, 1952 applies for a continuous period not less than 2 months immediately proceeding the date of my application for final withdrawal of my Provident Fund money.

X Signature of the member Date:

ADVANCE STAMPED RECEIPT Received a sum of Rs. __________________( Rupees _______________________________________________ From ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. EMPLOYEES PROVIDENT FUND towards the settlement of my Provident Fund account. Cheque No. _____________________ Date:_______________________

Rs. 1.00 Revenue Stamp

X Signature of the member

(For office use only) Account settled in Part / Full Entered in Withdrawal Register ICICI PRUDENTIAL LIFE INSURANCE CO. LTD EMPLOYEES PROVIDENT FUND Trustees

Address for sending the form- ICICI Prudential Life Insurance Co. Ltd. -Shared Services-PF Department Gr .Floor, Vinod Silk Compound, Chakravarthy Ashok Road, Ashok Nagar, Kandivali - East, Mumbai - 400 101