AIL STAFF PROVIDENT FUND TRUST

PROVIDENT FUND WITHDRAWAL FORM

Name of Member (in Block Letters)

Fathers Name (or Husbands name in the case

of married women)

Name and Address of the Factory/

Establishment in which the member was last
employed

P F Account No.

Employee Code No

Designation in Alcatel-Lucent India Ltd.

7A

Date of joining

7B

Date of leaving service

Reason for leaving service

Full Postal Address (in Block Letters)

10

Pan. No. (Mandatory)

11

Mode of Payment

i.

By account payee Cheque sent for

direct credit to my savings bank
account

ii.

Cheque in favour of self sent by post

iii.

By postal money order at my cost

Savings Bank a/c no:

Bank s Name
Branch Address:

12

Personal e-mail ID (Other then Alcatel-Lucent

India Ltd.) (Mandatory)

13

Mobile No. Or any Contact No. (Mandatory)

DECLARATION OF NON EMPLOYMENT

I declare that I have not been employment in any factory/ establishment to which the Act applies for a continuous period of not less
than 2 months immediately preceding the date of my application for final withdrawal of my Provident Fund money.

Signature or left/right hand thumb impression of the member

ADVANCE STAMPED RECEIPT

Date:
Received a sum of Rs
(Rupees
) from AIL Staff Provident Fund Trust by
deposit in my savings bank account/ or by post to my mailing address towards the full and final settlement of my Provident Fund
Account.
Revenue
Stamp of
Rs 1/Signature or left/right hand thumb impression of the member

Note:
If your PF Membership in less than five years than please attach Form 16 from the Date of Joining to Date of
Leaving for services rendered in Alcatel-Lucent India Ltd for deduction of tax as per Income Tax Act 1961. In
absence of the said Form 16 along with your PF withdrawal Form, income tax will be deducted at maximum
rate (currently maximum rate is 30.90%).