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Sample Copy - Mphasis &finsource

The document is an application form for an employee seeking settlement of their provident fund. It requests basic employee details like name, employee ID, date of separation, reason for leaving, address and contact details. The employee also declares they have not been re-employed and authorizes deduction of income tax from their PF settlement amount.

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413 Harini Reddy
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69 views2 pages

Sample Copy - Mphasis &finsource

The document is an application form for an employee seeking settlement of their provident fund. It requests basic employee details like name, employee ID, date of separation, reason for leaving, address and contact details. The employee also declares they have not been re-employed and authorizes deduction of income tax from their PF settlement amount.

Uploaded by

413 Harini Reddy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Employee Code:

Mention your employee ID

APPLICATION FORM TOWARDS PROVIDENT FUND SETTLEMENT

To, Date :
The Trustees
Mphasis Group Employees Provident Fund
Bagmane World Technology Centre 3,Block B, 1st floor, Mention employee name as
Marthahalli Outer Ring Road, Doddenekundi, Mahadevpura,
per the company records
Bangalore - 560 048.

1. *I Mr /Mrs/ Ms.(Name in block letter) ceased to


be an employee of M/S Mphasis Limited with effect from (Date of Leaving)
on account of:-
(tick the below appropriate box)
Mention the Date of Separation
Mention the reason for leaving.
Reason for leaving

Retirement Medical unfitness  Death  End of Contract  Permanent settlement abroad

Resignation  Retrenchment  VRS  Termination  others (specify)

Mention father/husband name


*2 ) Parent Name (Husband name in case of married women) :

*3 ) Address for Communication : Mention yo_ur p_ostal ad_dress with PIN#

Mention your phone # & Email ID City:

*Pin Code: *Phone : *Email :

* Gender *PF No. KN/16573/ *PAN

*Employee Code EPS No. KN/16573/

*Date of Birth *Date of Joining

*Bank A/c no. *Bank Name


*Branch IFSC
*Branch Name
Code

Employee needs to sign here Fill above Information as they are mandatory *

* Signature of Employee Signature of Employer/Authorized official

1
DECLARATION

Mention your PF #
1) Declaration of Non-Employment

You are requested to settle my Provident Fund Account KN/16573/

I hereby declare that I have not been employed in any factory/establishment to which the Employees’ Provident Funds
and Miscellaneous Provisions Act,1952 applies for a continuous period of not less than two months immediately
preceding the date of my application for final withdrawal of my Provident Fund money.

Employee needs to sign here

* Signature of Employee

2) Authorizing for Deduction of Income Tax

The Board of Trustees of Mphasis Group Employees’ Provident Fund or any person authorized by it shall deduct Income
Tax as per the provisions of Income Tax from the payment of accumulated balance due to be paid which is not
exempted from Tax and liable to be included in the total income as provided under the Rule 8 or 10 of Part A of the 4 th
Schedule of the Income Tax Act, 1961.

I hereby agree with the terms and conditions described above.

Employee needs to sign here

* Signature of Employee

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