From : Date : / /

To,
The Trustees,
Infosys Limited Employees’ Provident Fund Trust,
C/o. Infosys Limited
Plot No. 44, Electronics City,
Hosur Road,
Bangalore - 560 100.

Dear Sir,

I would like to withdraw the amount in my Provident Fund Account with you.

I hereby declare that I have not been employed in any establishment, which is covered under the EPF
Scheme. The brief particulars of my employment with Infosys Limited are given below:

1 Employee Number :

2 Name in Full :

3 Father’s Name :

4 Permanent Address :

5 Date of Joining :

6 Date of Leaving :

7 Provident Fund A/c No :

8 Reason for Leaving :

9 Savings Bank A/c No.

:

10 Bank and Branch Details

Signature
Certificate by the Employer

The above particulars are correct. Please settle the Provident Fund Account.

Date : Authorised Signatory.