Proforma for application of withdrawal from Provident Funds Ministry of----------------- Department of-----------/office Application for withdrawal from------------------------------------------ (here enter the name of the Fund) 1. Name of the subscriber ---------------------- 2, Account Number --------------------- 3. Designation (with departmental suffix) --------------------- 4. Pay. --------------------- 5 Date of joining service and the date of Superannuation. --------------------- 6 .Balance at credit of the subscriber on the date of application as below: / (i) Closing balance as per statement for the year-------. (ii) Credit from-----------to---------- on account of monthly subscriptions. (iii) Refunds made to the Fund after the closing balance vide (i) above. (iv) Withdrawal during the period from-----------to------------- (v) Net balance at credit on date of application. ----------------- 7. Amount of withdrawal required ---------------------- 8. (a)Purpose for which the withdrawal is required--------------- (b) Rule under which the request is covered------------------- 9. Whether any withdrawal was taken for the same purpose earlier. If so, indicate the amount and the year. ---------------------- 10. Name of the Accounts Officer maintaining the Provident Fund Account------------ Signature of Applicant Name--------------------- Designation------------- Section/Branch---------- Dated: -
