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FOR SSC USE ONLY
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Request No. : 18R032008724
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Mobile No. : 7710807371
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Personal E-mail ID : abirami198810@gmail.com
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Date of Receipt :
PS No. : 20048911

(APPLICATION FOR WITHDRAWAL OF PROVIDENT FUND ACCUMULATION)

To,
The Board of Trustees,
LARSEN & TOUBRO OFFICERS AND SUPERVISORY STAFF PROVIDENT FUND,
Shared services Centre (Retirement Benefit Section),
4th Floor, Krislon house, Off Saki Vihar Road,
Saki Naka, Andheri (East),
Mumbai ±

I hereby request you to pay me the amount standing to the credit of my provident fund account.

PS No. 20048911

Name of the Member ABIRAMI RAJAGOPAL

Name of the Applicant

(in case of Death of the Member)

Relationship with Member

Other PS Nos. (allotted if any)

Address for Communication Permanent Address

Shakti Singh Quarter no 36 Type 03 CBI door no 226 tc 24/424 brindavan thycaud
Colony
Sector 12 Near Rajpoot bhavan sangeeth nagar trivandrum

Gandhi nagar Gujarat Opposite PRS appartments

KERALA KERALA

Pin code : 382012 Pin code : 695014

Entity L&T

Unit EAIC Location POWAI

Cadre EXECUTIVE II Dept. Code 300202316

Date of Joining 05-OCT-2012 PF Membership 05-OCT-2012

Date
Date of Leaving 19-FEB-2018 Reason for Leaving RESIGNATION

Reason for withdrawal Started Own Business

Mode of Payment NEFT

Bank Details Bank Account No. 124701503200

Bank Name ICICI BANK LTD - (LT

POWAI)
Bank Branch LT POWAI
IFSC Code ICIC0001247

PAN Number* ATSPR1143G

I certify that the particulars given above are true to the best of my knowledge.

Place:

Date:

 In case this information is not properly filled up and necessary enclosures are not attached,
it will not be possible for us to issue the TDS Certificate.

Enclosure(s):

Sr. No. Description

1 Proof of Employment (Copy of anyone - Service Certificate / Relieving letter / Pay slip /
Appointment letter)
2 Proof of Identity - (Copy of anyone - PAN Card / Aadhaar Card / Passport / Driving License)

3 A Cancelled cheque with your name mentioned. In case, name is not appearing on the cheque
leaf, a copy of Passbook/Bank Statement giving your Name & Account Number should be sent
along with a cancelled cheque.

Received a sum of `. ( rupees only) from

the trustees of LARSEN & TOUBRO OFFICERS AND SUPERVISORY STAFF PROVIDENT FUND by cheque/NEFT
in full and final settlement of my provident Fund account no.TH/THA/0000424/000/0153925

Place:

Date:
 Annexure to PF Withdrawal Form

Declaration from Employee Seeking withdrawal of PF accumulation having less than five
years of PF Membership

To,
The Board of Trustees,
LARSEN & TOUBRO OFFICERS AND SUPERVISORY STAFF PROVIDENT FUND
Mumbai - 400072

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I hereby confirm that, I accept the tax deduction at source from my PF accumulation at applicable rates on
account of not completing five year of c ontinuous service with the employer or PF membership with the
provident fund trust. I request you to settle my PF dues after deduction of applicable tax under the provisions
of Rule 10 to read with rule 9 of the fourth schedule of Income Tax Act, 1961. The copies of all necessary
Form-16 are enclosed for tax calculation.

Place :

Date :
 AUTHORISATION TO THE TRUSTEES

I, the applicant above named, do hereby a uthorize the trustees LARSEN & TOUBRO OFFICERS AND
SUPERVISORY STAFF PROVIDENT FUND to deduct and pay on my behalf to the company and/or to the LTKSPM
all such amounts as are due and payable by me to the company and/or to the LTKSPM towards the full and final
settlement of all my accounts with them.

Place :


Date :