ANNEXURE IV

DISCHARGE RECEIPT

PROVIDENT FUND NO-1

Name of the Employee:…………………………. ……. S.R.No.: …………Office: ...…….

RECEIVED From the Trustees of the LIFE INSURANCE CORPORATION OF INDIA,

Provident Fund No.1, a sum of Rs. …………………….. (Rupees
……………………………………………………………….) being the part withdrawal
under Amended Rule 27(A) of LIC of India, Provident Fund No.1 Rules.

Revenue
Stamp
Signature------------------

Witness:
Signature---- ------------------- Signature---- --------------------
Full Name …………………….. Employee’s Full Name …………………….
SR NO………………………… SR NO…………………….
Office:………………………… Office:…………………………………..
Occupation……………………. Address ………………………………
Address ………………………..

Dated at ………………….this……………. day of…………….

NB. The Discharge Receipt should be attested by any Class-I Officer of LIC of India
with his seal of office affixed thereto.

In case the Receipt is signed in a language other than English, the witness to
his/her signatures should give the following declaration:

I hereby declare that I have explained the contents given herein above to Sh./Smt/…………
I further declare that he/she has fully understood the same.

Signature……………………..
Full Name ……………………
SR NO………………………… .
Office..…………………………..
Address ………………………