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Form 19
Application Form for withdrawal of accumulation from Provident Fund
The Trustees, Employee No: 20532177
Address- Wipro PF Team
S3, 8th floor “A” wing, Location: Bangalore Division:
Doddakannelli Sarjapur Road,
Bangalore, Karnataka 560035.
Mail ID:kambaduru.saivikaskumar@gmail.com
Sir, Contact No. 9686641500
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.
2. Father’s Name:
3. PF Account Number: PYBOM00 Date of Leaving Service: DOB: 06/11/1996
4. Name & address of the employer in which the Member was last employed: WIPRO LTD
5. Ground on which the request for withdrawal is made (tick the reason for leaving): Resigned/ Abroad/ Retirement
6. Mode of Payment: NEFT
Name of the Bank: _State Bank Of India______________________ Bank a/c no
32633145882________________ PAN NO.GWFPK4318Q____________
7. Present Postal Address
Room. No - 503, Sri Virat gents Pg , Venkateswara layout, BTM 1st stage, Bangalore - 560068
DECLARATION BY EX-EMPLOYEE
Certified that the particulars furnished by me are correct
I, Kambaduru Sai Vikas Kumar_______________________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.
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
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Witness details: Signature of the Employee
Name:
Address:
Contact No: 9686641500 Witness 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 Pan Card & AADHAR Card - Mandatory*
4 Self-Declaration Form*
5 Applications should be submitted after 60 days from the Date of Leaving
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