DATE OF RECEIPT : APPLICATION FOR WITHDRAWAL OF PROVIDNET FUND ACCUMULATIONS The Trustees, Ultra Tech CemCo Provident Fund

AWARPUR 442 917 Dear Sirs, Sub: SETTLEMENT OF PROVIDENT FUND DUES PART - A 1a NAME OF THE MEMBER 1b NAME OF THE APPLICANT (In case of DEATH of member) 1c RELATIONSHIP WITH THE MEMBER 2 COMPLETE POSTAL ADDRESS FOR COMMUNICATION:

PIN CODE: 3 NAME OF THE OFFICE/WORKS/UNIT IN WHICH THE MEMBER LAST EMPLOYED 4a P.S.NO. OF THE MEMBER (As a confirmed employee) P.S.NO. OF THE MEMBER AS A GET 4b (If any) 4c P.S.NO.AS A CASUAL/TEMPORARY WORKMAN(if any) 5a DATE OF JOINING COMPANY 5b DATE OF JOINING P.F. IN PREVIOUS EMPLOYMENT (In case PF Transfer received/ applied for) 6 DESIGNATION / CADRE 7 DEPARTMENT NAME & CODE 8 DATE OF LEAVING COMPANY 9 CAUSE OF LEAVING
(Strike out whichever is not applicable. Please specify the exact cause of leaving in all other cases

TEL. NO:

RETIREMENT/ RESIGNATION/TERMINATION /DISMISSAL/DEATH

10 Please note:THE STATUTORY WAITING PERIOD IS OF TWO MONTHS from the date of leaving the company
whether a WAIVER is sought in respect of Statutory waiting period

YES/NO (P.T.O)

11 if answer to the above is "YES" please tick the relevant cause mentioned hereunder a. proceeding abroad. The b.Service terminated c.Started own business, copies of Partnership Deed/Factroy copies of passport, visa on medical grounds. Licence/Sales Tax Registration/ Shops & Establishment & tickets enclosed Copy of the Certificate Registration certificate enclosed from the Company's Medical Officer enclosed 12 MODE OF REMITTANCE:(Please tick the relevant) a. Cheque to be collected b.Cheque to be sent by c.Cheque to be sent to the d.Credit Advice to be by theApplicant POST at the address BANK directly at the following raised on the Accouting personally. mentioned for address Centre from which last communication pay was drawn Savings Bank Account Name of the Bank Name of the Branch Complete Postal address of the Bank branch PIN CODE: Date: Place: Signature of the Applicant PART - B AUTHORISATION TO THE TRUSTEES I, the applicant abovenamed, do hereby authorise the trustees of Ultra Tech CemCo Provident Fund to deduct and pay on my behalf to the Company and /or to the any other agencies all such amounts as are due and payable by me the Company and / or any such agencies towards the full and final settlement of all my accounts with them. Date: Place: PART - C ADVANCE STAMPED RECEIPT Received from the trustees of Ultra tech CemCo Provident Fund a sum of Rs. _________ towards the full & final settlement of the Provident Fund Account mentioned above. Date: Place: FOOTNOTE:
Affix Re.1/- Revenue Stamp

Signature of the Applicant

Signature of the Applicant

The copy of respective documents as mentioned hereunder should be attached alongwith the application

Retirement/Resignation : Retirement / Resignation Acceptance Letter. Termination : Termination letter Dismissal : Dismissal Order Death : Death Certificate, Affidavit & Indemnity Bond(When the nomination is not in favour of the applicant) Others : Documentary proof substantiating the reason for leaving

FORM NO. PF - V DETAILS FOR SETTLEMENT OF P.F. DUES OF THE EX- EMPLOYEE (TO BE FILLED IN BY THE RESPECTIVE ACCOUNTS DEPARTMENT) 1. CONTRIBUTION FOR THE PRECEDING SIX MONTHS
YEAR MONTH PF BASED SALARY/ WAGES MEMBER'S SHARE OF PF CONTRBUTION VPF COMPANY'S RECOVERY OF EPS SHARE OF PF REFUNDABLE CONTRIBUTION CONTRIBUTION PF LOAN NO.OF DAYS OF NON CONTRIBUTING SERVICE

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
2. DETAILS OF TAX DEDUCTED AT SOURCE FROM INCOME CHARGEABLE UNDER THE HEAD " SALARIES" As per FORM NO. 16 (Under I.T. Rule 31(1)(a) (TO BE FURNISHED ONLY IF THE TOTAL SERVICE IS LESS THAN 5 YEARS)
DETAIL S/F.Y. Gross Salary Standard Deduction Tax on Employment Gross Total Income Aggregate of Deductible Amount under Chapter VI-A (Please see note 6) Rebate & Relief under Chapter VIII(Please see note 7) Taxdeducted at source Employer's share of PF Contribution Interest on Employee's Contribution Interest on Employer's Contribution (TO BE FILLED IN BY RETIREMENT BENEFIT SECTION)

FORM NO. PF -V (contd.) 3 LAST DATE UPTO WHICH THE WAGES SALARY HAS BEEN PAID 4 LAST MONTH IN WHICH RECOVERY TOWARDS PF REFUNDABLE
LOAN INSTALLEMNT & INTEREST WAS MADE ____________________________________

(Applicable if no recovery was made as above in preceding six months) ___________________________

5 OTHER RECOVERIES a. Credit Society dues b. Salary Dues c. Itger Dues (if any)

Rs. _____________________ Rs. _____________________ Rs. _____________________

Date:

(Authorised Signatory)

INSTRUCTIONS TO THE ACCOUNTS DEPARTMENT 1 Please ensure that the application is made in the prescribed form only and all the relevant documents as per the Application form are enclosed. 2 Please ensure that the Monthly PF Recovery details are furnished upto and including the Date of Leaving 3 Please ensure that all the relevant details as per Application Form as well as FormNo. PF - V have been filled in. In case on no applicability of any details, please write " Not Applicable" in the space provided for 4 Incomplete Form in any respect shall be rejected. 5 If the Applicationis preferred by the nominees(s) of the deceased employee, please ensure that the signture/Thumb impression of the applicant(s) is attested by the concerned Welfare Dept/ Regional Personnel Dept. 6 Amount consists of payments to certain pension funds(80CCC), Medical Insurance Premia(80D), Medical Treatment/ Maintenance expenses for handicapped dependent (80DD)/(80DDA), Medical expenses on specified disease/ ailments (80DDB), Donations to certain funds/ charities (80 G) allowed to be considred for TDS. Income from services rendered outside India (80RRA). Deduction for permanent physical disability(80U) 7 Amount consists of PF/VPF Contribution. LIC/ULI premium & Retirement Benefit Plan of UTI, CTD & PPF NSC & accrued interest. Repayment of Housing Loan, Deposit in National Housing Bank. National Savings scheme, Equity Linked Savings Scheme. Approved Units/ Issue of public companies for infrastrucure & Power sectors, Rebate & Relief under section 88A & 89