Guidelines for filing Provident Fund Withdrawal form:

1. Please fill the form in CAPITAL Letters only.

2. Documents Required :

a) Original cancelled cheque (it should be Individual Savings account on employee’s name,
Joint saving account is admissible only if it is with spouse , in such cases, last name of
both should be same)

b) A copy of Certificate of Registration of Marriage, in case of change in surname post

marriage (Self attested copy). The members name on form and cancelled cheque should
be the same.

c) A copy of Gazette Notification, if change in Name of employee. (Self attested copy) The
members name on form and cancelled cheque should be the same.

3. A person has to remain unemployed for continuous period of 2 month immediately

preceding the date of application for withdrawal of Provident Fund.

4. The following are most common reason for rejection of the form. Therefore, you are
requested to fill the form carefully.

a) Incomplete Forms.

b) Complete signature not made wherever overwriting / whitener used for making
correction on form.

c) The member’s name on the form and on cancelled cheque not matching.

d) Non-submission of any required documents.

e) Forms filled with illegible handwriting.

Kindly send Provident Fund withdrawal form along with required documents to the respective
Regional HR office.
 SBI LIFE INSURANCE CO LTD EMPLOYEES’ PROVIDENT FUND 
FORM FOR WITHDRAWAL OF PROVIDENT FUND ACCUMULATIONS 
ILLUSTRATION
Personal email id:nehasingh@gmail.com
1. Name of Member:
NEHA ANUJ SINGH
______________________________________________________________________  Mobile No: 090000 00009
(In Block Letters) FIRST NAME    FATHER / HUSBAND’S NAME  SURNAME UAN : 100000 000001

2. Name of Claimant : Applicable in Death case only

N.A
______________________________________________________________________ 
(other than member)  FIRST NAME   FATHER / HUSBAND’S NAME  SURNAME 

3. Emp. No. 12345
: _______________________   4. Location BORIVALI, MUMBAI RO
: ________________________ 

5. Account No.
12345
: _______________________   6. PAN No. AHSPP6205B
: ________________________ 

7. 1-APRIL-2008
Date of Joining  : _______________________ 31-DEC-2014
 8. *Date of Leaving Service:________________ 
9. RESIGNED
Reason For Leaving Service: ____________________________________________________________
10. Full Postal Address: __________________________________________________________________
(in block letters)
101, BLDG No.10, MATOSHREE CHS LTD, SHANTI NAGAR, SANTACRUZ - EAST, MUMBAI
____________________________________________________________________ 
_ 
400 067
________________________Pin Code:   State:  MAHARASHTRA
__________ 

11. Mode of Remittance: (Ö) put a “ Tick” in the box against the one opted.

(      ) (a) By account payee Cheque     To be sent at the address given against item no. 10 

(      ) (b) By account payee cheque to be  Bank Details:  Name appearing

sent direct to Bank for credit to 
1000100010 on Cheque should
my S.B. A/c. under intimation     S.B. Account No.____________________________ 
to me. 
match with
STATE BANK OF INDIA
( Advance Stamped Receipt    Name of the Bank ________________________________ member's name
Furnished below ).  _______________________________________________ 
SANTACRUZ-EAST
Branch  ________________________________________ 
AMRUT NAGAR, RPS ROAD,
Full address of the bank____________________________ 
SANTACRUZ - EAST, MUMBAI-400 067.
_______________________________________________ 

Certified that the particulars are true to the best of my knowledge. 
The applicant has signed / thumb impressed before me. 

For SBI Life Insurance Co Ltd Employees’ Provident Fund  Signature of the member / claimant 

Trustee  Date  : 

DECLARATION OF NON ­ EMPLOYMENT 
I  declare  that  I  have  not  been  employed  in  any  factory    /  establishment  to  which  the  EPF  &  MP  Act,  1952 
applies  for  a  continuous  period  not  less  than  2  months  immediately  preceding  the  date  of  my  application  for 
final withdrawal of my Provident Fund money. 

Date: __________________  Signature of the member ___________________
 ADVANCE STAMP RECEIPT 

Received a sum of Rs. _____________ (Rupees __________________________________________) 
from  "SBI Life Insurance Co Ltd Employees’ Provident Fund" towards the settlement  of  my  provident fund 
account. 
Cheque No. _______________  Date: _____________ 
Re. 1.00 
X 
Revenue 
Stamp
Signature of the member / claimant 
(For office use only) 
Account settled in Part / Full  Entered in Withdrawal Register 

Initials 
Enclosures: 

a.  Form 16 (If membership is less than 5 years for all the earlier years) 
b.  Visa Copy  (In case of going abroad) 
c.  Death Certificate (In case of death) 
d.  Doctor’ Certificate (In case of medical unfitness) 
e.  Final Settlement Computation Sheet 
f.  Any other document (Please specify) 

Note:  * In case of death please write date of death 
 SBI LIFE INSURANCE CO LTD EMPLOYEES’ PROVIDENT FUND 
FORM FOR WITHDRAWAL OF PROVIDENT FUND ACCUMULATIONS 
Personal email id
1. Name of Member: Mobile No:
______________________________________________________________________ 
UAN :
(In Block Letters) FIRST NAME    FATHER / HUSBAND’S NAME  SURNAME 

2. Name of Claimant :
______________________________________________________________________ 
(other than member)  FIRST NAME   FATHER / HUSBAND’S NAME  SURNAME 

3. Emp. No. : _______________________   4. Location : ________________________ 

5. Account No. : _______________________   6. PAN No. : ________________________ 

7. Date of Joining  : _______________________  8. *Date of Leaving Service:________________ 

9. Reason For Leaving Service: ____________________________________________________________
10. Full Postal Address: __________________________________________________________________
(in block letters)

____________________________________________________________________ 
_ 

________________________Pin Code:   State:  __________ 

11. Mode of Remittance: (Ö) put a “ Tick” in the box against the one opted.

(      ) (a) By account payee Cheque     To be sent at the address given against item no. 10 

(      ) (b) By account payee cheque to be  Bank Details: 
sent direct to Bank for credit to 
my S.B. A/c. under intimation     S.B. Account No.____________________________ 
to me. 
( Advance Stamped Receipt     Name of the Bank ________________________________ 
Furnished below ).  _______________________________________________ 
Branch  ________________________________________ 
Full address of the bank____________________________ 
_______________________________________________ 

Certified that the particulars are true to the best of my knowledge. 
The applicant has signed / thumb impressed before me. 

For SBI Life Insurance Co Ltd Employees’ Provident Fund  Signature of the member / claimant 

Trustee  Date  : 

DECLARATION OF NON ­ EMPLOYMENT 
I  declare  that  I  have  not  been  employed  in  any  factory    /  establishment  to  which  the  EPF  &  MP  Act,  1952 
applies  for  a  continuous  period  not  less  than  2  months  immediately  preceding  the  date  of  my  application  for 
final withdrawal of my Provident Fund money. 

Date: __________________  Signature of the member ___________________
 ADVANCE STAMP RECEIPT 

Received a sum of Rs. _____________ (Rupees __________________________________________) 
from  "SBI Life Insurance Co Ltd Employees’ Provident Fund" towards the settlement  of  my  provident fund 
account. 
Cheque No. _______________  Date: _____________ 
Re. 1.00 
X 
Revenue 
Stamp
Signature of the member / claimant 
(For office use only) 
Account settled in Part / Full  Entered in Withdrawal Register 

Initials 
Enclosures: 

a.  Form 16 (If membership is less than 5 years for all the earlier years) 
b.  Visa Copy  (In case of going abroad) 
c.  Death Certificate (In case of death) 
d.  Doctor’ Certificate (In case of medical unfitness) 
e.  Final Settlement Computation Sheet 
f.  Any other document (Please specify) 

Note:  * In case of death please write date of death