Form 19

APPLICATION FORM FOR WITHDRAWAL OF ACCUMULATION FROM

PROVIDENT FUND.
The Trustees
WIPRO SYSTEMS PROVIDENT FUND TRUST
Sigma Soft Tech Park,
Beta Block, II Floor,
Ramagondanahally, Varthur,
Bangalore- 560 066.
Sir,

I hereby request you to pay the full amount standing to my credit in the Fund after making such
deduction as may be authorised under your Provident Fund Rule.
1. Name (in block letters) : Sri / Smt
1 a) e-mail id
2. Fathers Name :
3. Employee Number :

Locn : Divn :

4. PF Account Number :

KN/BN/11394/

5. Date of leaving Service :

6. Name & address of the employer in which the Member was last employed :
WIPRO TECHNOLOGIES A DIV OF WIPRO LTD
7. Ground on which the request for withdrawal is made (Reason for leaving) :
(Please read the instructions on 2nd page & provide the proof)
8. Mode of Remittance:-Account Payee cheque will be drawn in your favour along with the account number and
the bank, you need to deposit the cheque in the same bank mentioned below
a. S.B. Account No:b. Name of the Bank:(In block Letters)

Note: Following proofs are mandatory, else application will be rejected :1. Copy of a cancelled cheque leaf along with the application.
2. Copy of photo id card.. for ex. Driving license, Voter id, Pan card, etc..,

Wipro Technology HRD

Company Confidential

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9. Complete Permanent Postal Address:

------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Pin: ------------------------------ PH No: ________________________

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

Date :

Signature of the member:

Certified that the particulars furnished by the above member are correct as per our records.

Signature of the Employer/HR Department With office seal.

The member should state whether he:
a.

is retiring from service in the industry attaining the age of superannuation

b.

is retiring on account of permanent and total incapability for work in any industry due to bodily or
mental infirmity, the following documents to be produced.
Member should produce the certificate by a registered medical practitioner or the medical
officer of the establishment should be enclosed.

c.

is migrating from India on permanent settlement abroad or for Job abroad or for higher studies abroad, the following documents
to be produced.
Member should produce copies of Passport, visa and air ticket/Accepted offer letter/Admission letter.

d.

has not been employed in an establishment to which the scheme applies for a continuous period of not less than sixty days
immediately preceding the date of application.
Declaration from the Ex-employee for non-employment for a period of sixty days in any establishment to which the
scheme applies from the date of leaving company.

DECLARATION BY EX-EMPLOYEE
I, _______________________declare that I have not been employed in any establishment/Factory to which the
act applies for a continuous period not less than 2 month immediately preceding date of my application for final
withdrawal of my Provident Fund money.

Signature of the Member

Witness:
Name:
Complete Address
With contact number
& e-mail id

Wipro Technology HRD

Company Confidential

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