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 Letter of Indemnity

I, ............... a member of the Employees' Provident

(;;;;;;;:;;"
Fund, and holder of National ldentity Card No. ................residing at

"::--::
emproyed
",
, .......... :'-l:...
(Occupation)
... .. . ; ....... ::':- ::" :**
(Nane and address of the insritttlion)
from .......... ........-..to ..... that the said institution is not

in operation now and that the whereabouts of the employer are not known nor traceable.

I also declare that during the period, I served at the said ......in;;;;;;-;;;;;;.-;i;;;-;;;;;;;;;1.-.-

contributions had been paid to the E.P.F. on my

behalf under membership number """""" "iii;;i' ..-................ , that all contributions
iiiiiii, i, t
relating my membership number mentioned above have been deposited in the Central Bank of

sri Lanka in the name of ..----.---i;;;;;-;;i;;it------ -----and that r am

the person known also by the said name .........

(Full Name)

I do hereby unconditionally agree that in the event of it being established that some other person

by the said name .... had served in the said

(Name in CBSL)

or the said person's Employees' Provident Fund Membership number was

(Employer Name )
......?ii,;ii..;;W;.ii;.)..-.--.-..-. to reimburse the central Bank of Sri Lanka with all the
benefit proceeds awarded to me on so doing, I also agree unconditionally to pay interest on the proceeds
drawn up to the date of the refund as determined and estimated by the Central Bank of Sri Lanka.
Signed on this ...day of .............. -Two Thousand ............

Signature
We certifu that the above signature was placed in our presence.

Witness : (l\ Signature : .................

Name : ................-
N.I.C. No. :.....-....
Address : ..................

(2) Signature : .................

Name : ...............-.
N.I.C. No. :..........
Address : ..................

(N. B.- Grama Seva Niladhari and Asst. Govt. Agent are the most suitable witness).
sfc. (r0076,