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Form 19
Application Form for withdrawal of accumulation from Provident Fund
The Trustees, Employee No: _Wipro ID_________
Address- Wipro PF Team
S3, 8th floor “A” wing,
Doddakannelli Sarjapur Road, Location: Division:
Bangalore, Karnataka 560035.
Mail ID:
Sir, Contact No. Mobile No
I hereby request you to pay the full amount standing to my credit in the Fund after making such deduction as may be
authorized under your provident Fund Rule No. 22 and 23.
1. Name (in block letters): Sri / Smt. Name of the Member
2. Father’s Name: - Name of Member’s Father
3. PF Account Number: PY/BOM/ Refer Payslip for PF A/c No Date of Leaving Service: DD/MM/YY DOB: DD/MM/YY
4. Name & address of the employer in which the Member was last employed: WIPRO LTD - DATE OF JOINING
5. Ground on which the request for withdrawal is made (Reason for leaving): Resigned /Abroad /Retirement
6. Mode of Payment: A/c Payee Cheque, S .B. A/c No. ____Member’s Saving Account_____________________
Name of the Bank: _____________________________________________ PAN NO. _________________ *
7. Present Postal Address (Where you want the Cheque to be sent) ____________________________________________
DECLARATION BY EX-EMPLOYEE
Certified that the particulars furnished by me are correct
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 Fun d
money.
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
Witness: Signature of the Member
Name: ________________________________________
Address: ______________________________________________________________________________________
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Contact No: __________________________________
Sign______________________________________
Note: Following proof are Mandatory, else application will be rejected
1) PAN CARD
2) Original Cancelled cheque leaf or copy of Bank statement:- 2 sets .Bank A/c should be same as your Wipro salary account. If
salary A/c is closed, Please submit closure letter along with new cheque leaf & duly signed or copy of bank statement.
3) Address proof
a) Should match with Wipro Records
b) If address does not match with Wipro records then we require documentary proof of the same
Signature of the Employer/HR Department With office seal
The member should state whether he/she:
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. & produce the certificate by a registered medical
practitioner or the medical officer of the establishment should be enclosed.
c. Migrating from India on permanent settlement abroad or for Job abroad or for higher studies abroad, the
following documents to be produced:- copies of Passport, visa and air –ticket/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.
Please note the following:
1. “Income Tax shall be deducted at source (TDS) if at the time of payment of the accumulated PF balance is
more than or equal to Rs. 50,000/-, with service less than 5 years.
2. Please note that for any PF transactions in future, you are required to ensure UAN (universal account
number) is activated.
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Checklist
Sl. No Form 19 applications to settle Provident Fund Status
1 From 19 - Original Applications has to be duly signed by the Employee*
2 Cancelled Cheque Leaf or Bank Statement*
3 Copy of the Relieving Letter*
4 Pan Card & AADHAR Card - Mandatory*
5 Self-Declaration Form*
6 Applications should be submitted after 60 days from the Date of Leaving
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