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FORM NO.

19
APPLICATION FORM FOR WITHDRAWAL OF ACCUMULATION

FROM PROVIDENT FUND


Purpose
To withdraw the accumulated fund after resignation from Wipro Ltd

Process
In case ex-employees want to withdraw the PF, they have to fill up Form 19 and get it
attested by Gazetted officer and send it to Amalner Trust.
Before they release PF, Amalner Trust will get confirmation form us whether any dues
are outstanding.

Address to be sent to
Attn: Mr. Rohit Kumar/Mr. Sunil Shede
The Chairman / Board of Trustees,
WIPRO Limited Employees Provident Fund,
AMALNER (Distt: Jalgaon)
STD Code No. 02587
222453
Fax. No. (02587)
222985

FORM NO. 19
APPLICATION FORM FOR WITHDRAWAL OF ACCUMULATION
FROM PROVIDENT FUND
To,
The Chairman / Board of Trustees,
WIPRO Limited Employees Provident Fund,
AMALNER (Dist: Jalgaon)

Date of Joining: __________________


Date of Leaving: __________________

I hereby request you to pay me the full amount standing to my credit in the fund after making such
deduction as may be authorised under your Provident Fund Rule Nos. 22 & 23.
[1]

Name (In block letters)

| Shri. /Smt. _________________________________

[2]

Present full address

|___________________________________________
|___________________________________________
|___________________________________________
| Pin Code_______________

[3]

Provident Fund Account No.

| MH/948/___________________________________
| Employee No. ______________________________
| Division ___________________________________

[4]

Name and address of the


present employer.

|___________________________________________
|___________________________________________
|___________________________________________
|___________________________________________

[5]

If there is any Provident Fund


Scheme under present
Employment?
|

|
| YES / NO (If NO, please send certificate).

[6]

Ground on which the request for


|___________________________________________
withdrawal is made ?
|___________________________________________
(Please give reason for withdrawal) |___________________________________________

[7]

Date of leaving India in case


migrating a broad.
(Please attach Xerox copy of
passport visa etc.)

|___________________________________________
|
|
|

[8]

The payment may be made by


D.D. at my cost / Cheque payable
at station (Please give name of
town (SBI) Code No.)

|___________________________________________
|___________________________________________
|___________________________________________
|___________________________________________

[9]

Particulars of last subscription


i. e. month and amount.

|___________________________________________
|___________________________________________

I certify that the particulars given above are true to the best of my knowledge. I hereby pledge to
indemnity you against any claim for Income Tax that may arise in future in this connection.

Date:

Signature or left (for male), right (for female) hand


thumb impression of the member.
\\ 2 \\

The member should state whether he (a) is retiring from service in the industry after attaining
the age of superannuation (b) is retiring on account of permanent and total in capability for work in
any industry due to badly of mental infirmity (c) is migrating from India for permanent settlement
abroad, (d) has not been employed in factory to which the scheme applied for a continuous period of
not less than two months immediately preceding the date of application.
If the claim for withdrawal in made on grounds mentioned in foot note (b) above, a certificate
be a registered Medical Practitioner Officer or the Medical Officer of the factory should be enclosed if
the claim for withdrawal is made on grounds mentioned in (d) above a certificate from such authority
as may be specified of non-employment for a period of two months if any factory to which the scheme
applies, should be enclosed, if the claim for withdrawal in made on ground mentioned in (E) the
member should give details regarding Passport No., Visa No., Flight No. etc.

CERTIFICATE
This is to certify that Shri / Smt. _____________________________________ has
signed before me the application for withdrawal of Provident Fund money. He / She is not
employed in any factory of organisation where is any provision for Provident Fund under
Employees Provident Fund Act, 1952.
Date:

Name:
Address:

Signature of attestee
Designation and Seal
=.=.=.=.=.=.=.=.=.=.=.==.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=
Name of person authorised to the application.
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]

Gazetted Officer
Post Master of Sub Postmaster
President of the Village Union
President of Village Panchayat
Chairman / Secretary of Municipal / District Local Board.
Village Munsif
M.L.A.
Member of Borough Municipalities and Municipal Corporation.

File: pf\msw\FORM-10-PF (kd)