PF Withdrawal Claim Form

ARICENT TECHNOLOGIES PF TRUST
The Trustees
Aricent Technologies Provident Fund Trust
5,Jain Mandir Marg
Connaught Place
New Delhi- 110 001
Dear sir,
I hereby request you to pay me the full amount standing to my credit in the fund after
making such deductions as may be authorized under the scheme. My Particulars are as
below:
1. Employee ID : 36014
2. Employee Name : MOHAMMED NIZAMUDDIN
3. Father Name : MOHAMMED OSMAN ALI
4. Permanent Address : H.NO:16-2-751/6/C, M.C.NO: 880, KARAN
BAGH, SAIDABAD COLONY,
HYDERABAD, PIN CODE: 500059
5. E-Mail ID : [email protected]
6. Date of Birth : 12-03-1991
7. Personal Phone No. : +91-8985754100
8. Date of Joining : 16/12/2013
9. Date of Relieving : 01/01/2015
10. Date of Regularization (E2 Fresher) : -
11. Whether worked Onsite (Long Term): -
12. Period of Onsite :-
13. Date of Issuing Reliving letter: 01/01/2015
14. Bank Name (For crediting amt. into your account.) : STATE BANK OF
HYDERABAD
15. Bank Account No. : 62103456727
16. IFSC code. : SBHY0021364
17. PF Account No. :
I certify that the particulars given above are true to the best of my knowledge
HR Employee
Authorized Signatory Signature

The Trustees
5, Jain Mandir Marg (Annexe.)
Connaught Place
New Delhi- 110 001
SUB: REQUEST FOR WITHDRAWAL OF PF MONEY.
Dear Sir,
I hereby request you to pay me the full amount standing to my credit in the Fund after
making such deductions as may be authorized under the scheme. My particulars are as
below:
1. Name : __________________________________
2. Father’s/Husband’s Name : __________________________________
3. PF Account No. : DL/14510/_________________________
4. Date of Joining : __________________________________
5. Date of Leaving Service : __________________________________
6. Ground on which the request
for withdrawal is made : __________________________________
7. Date of leaving India, if applicable : __________________________________
8. Permanent A/c No. (of Income Tax) : __________________________________
9. Address to which cheque to be sent : __________________________________
___________________________________
___________________________________
___________________________________
___________________________________
I certify that the particulars given above are true to the best of my knowledge.
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(Amended till date
applies for a continuous period of not less than 02 months immediately preceding the
date) of this application for final withdrawal of my P.F money. I further declare that I do
not propose to join any job in India in the near future.
Signature:
Emp No: ___________
Contact Email Address: ……………………………………………….

Declaration-I
The Trustees
Connaught Place
New Delhi- 110 001
DECLARATION
I, ______________________________________S/o _____________________________
resident of ______________________________________________________________,
do hereby declare that I am going abroad for an overseas assignment/higher
studies/currently employed abroad and that I do not propose to join any job in India in
near future.
I hereby agree and undertake to keep you harmless and fully indemnified from and
against all losses, costs or damages which you may suffer or incur if at any time my
withdrawal of Provident Fund amount is proved to be based on a false declaration at any
time in future.
WITNESS: Signature of Declarant

Emp No.
1.-------------------------- (Signature)
Name:
Address:
2.-------------------------- (Signature)
Name:
Address:
* strike whichever is not applicable
Declaration-II
The Trustees
Connaught Place
New Delhi- 110 001
DECLARATION
I, ____________________________________ S/o ______________________________

resident of _____________________________________________________________,
do hereby 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 two months from the date of my relieving from
Aricent Technologies (Holdings) Ltd. and hence I request you for final withdrawal of my
Provident Fund amount.
I hereby agree and undertake to keep you harmless and fully indemnified from and
against all losses, costs or damages which you may sustain or incur by reason of my PF
withdrawal on the above statement proving to be untrue.
WITNESS: Signature of Declarant

Emp. No.
1.-------------------------- (Signature)
Name:
Address:
2.-------------------------- (Signature)
Name:
Address:
DISCHARGE PRE-RECEIPT
Received with thanks from Aricent Technologies Provident Fund Trust, 5,

Jain Mandir Marg (Annexe.), Connaught Place, New Delhi- 110 001, a sum
of Rs……….…... (Rupees ………………………………….
…………………………………… ………) only by Demand Draft/Account
Payee Cheque No……………… dated..…….………drawn on HDFC Bank
Limited, Kasturba Gandhi Marg, New Delhi in full and final settlement of
my P.F money including interest.
My PAN (allotted by Income Tax department) is _____________________.
Signature of Recipient

PF Withdrawal Claim Form

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ARICENT TECHNOLOGIES PF TRUST

Authorized Signatory Signature

SUB: REQUEST FOR WITHDRAWAL OF PF MONEY.

Contact Email Address: ……………………………………………….

WITNESS: Signature of Declarant

* strike whichever is not applicable

I, ______ S/o

WITNESS: Signature of Declarant

Received with thanks from Aricent Technologies Provident Fund Trust, 5,

My PAN (allotted by Income Tax department) is _____________________.

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