FORM NO.

19

THE EMPLOYEES PROVIDENT FUND SCHEMENT 1952

(Form to be used by a member from the withdrawal of accumulation standing to his credit in the fund.)

To,
Hindustan Computers Limited.
Employees Provident Fund Trust
E-4,E-5,E-6, Sector 11, Noida-201301, U.P.,

I hereby request you to pay the full amount standing to my credit in the fund after making such deductions
as may be authorized under paras 69 and 71 of the scheme.

1. Name (IN BLOCK LETTERS) :

2. Father’s Name (or Husband’s name in the case of married :
women)
3. Name and address of Factory/Establishment in which the :
member was employed
4. (a) Date of Joining in HCL INFOSYSTEMS LTD. :
(b) Employees Code No :
(c) PF Account No UP/11476/ :
(d) PAN No :
(e) Banker’s Name and Address :

(f) Account No :
(Please enclosed Cancelled Cheque Leaf as proof)
5. (a) Ground on which the request for withdrawal is made :
(see foot note overleaf)
(b) Date of Leaving Service / Last Working Date :
6. Date of Leaving India :
(i) In the case of migration for Permanent settlement
abroad (para 69(2)(a))

(ii) For at least a year

7. Permanent Address :

8. Particulars of the last subscription (i.e, month and amount) :

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/Establishment to which the act applies for a continuous period of not less then
two months immediately proceeding the date of my application for final withdrawal of my PF money (See
Foot Note 2 Overleaf)

Signature of Member
Pto….2/-
 -2-

Certified that the above declaration has been signed before me and the statement made above by
Mr./Ms______________________________________ is correct.

Signature_____________________

Designation ___________________

Official Seal:

- - - - - - - - - - - - - - -
ADVANCED STAMPTED RECEIPT

Received of a sum Rs ___________________(Rupees__________________________________

_________________________) dated ____________________________ in full and final settlement of

Provident Fund Account.

Fix Re 1
Revenue Stamp
Signature of the claimant

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

To be attested with official seal and date by any one of the following official:-

1. Magistrate or
2. Gazetted office or
3. Post/Sub Post Master or
4. President of the Village Union or
5. President of the village panchayat where there is no Union Board or
6. Chairman/Secretary/Member of Municipal/Director of Local Board or
7. Member of Parliament/Legislative Assembly or
8. Member of the Central Board of Trust Deed/Regional Committees.

NOTE 1. 1. The member should state whether he (a) is retiring from service after attaining
the age of 55 years . (b) is retiring on account of permanent and total incapacity for work in
Industry due to bodily or mental infirmity. (c) is migrating from India for Permanent
Settlement abroad. (d) being a national of country other than Indian is leaving India at least
for a year. (e) has not been employed. In any factory to which the Scheme applied for a
continuous period of not less than six months immediately preceding the date of
application.

2. If not applicable strike out the words.

3. If the claim for withdrawal is made on ground mentioned in (e) of note above a certificate by the
factory should be enclosed.
4. If payment is required by cheque, an advance stamped receipt should be enclosed.

Note 2. : As per Rule your Final PF Withdrawal form will be submitted to PF Trust after 60 days of your Last
Working Date.