FOR SSC USE ONLY

Request No.
: 16R032000276
Mobile No.
: 9677739939
Personal E-mail ID : TSASIDHAR@LTFINANCE.COM
Date of Receipt
:
PS No.
: 735944
(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 400072

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

PS No.

735944

Name of the Member

SASIDHAR T.P.

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

NO39 2 MAIN ROAD

NO39 2 MAIN ROAD

ANNAMALAI NAGAR

ANNAMALAI NAGAR

KATPADI

KATPADI

VELLORE

VELLORE

TAMILNADU

TAMILNADU

Pin code : 632007

Pin code : 632007

Entity

LTF

Unit

LTF

Location

CHENNAI

Cadre

FL II

Dept. Code

A204470135

Date of Joining

02-APR-2008

PF Membership
Date

02-APR-2008

Date of Leaving

09-FEB-2015

Reason for Leaving RESIGNATION

Reason for withdrawal

Unemployed for more than two months

Mode of Payment

NEFT

Bank Details

Bank Account No.

06941140000703

Bank Name

HDFC BANK (VELLORE TAMILNADU)

Bank Branch

VELLORE TAMILNADU

IFSC Code

HDFC0000694

PAN Number*

AWBPS6965R

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

Signature of the Member/Applicant

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

ADVANCE STAMPED RECEIPT

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.MH/424/0046987.

Place:
Date:

Affix Re. 1
Revenue
Stamp &
Sign

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

Sub.: Tax deduction from PF accumulation

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 :

Signature of the Member

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 :

Signature of the Member/Applicant