From No.

19 (Trust)

To,
S.K.Sarma, Associate Director-Head (HR & Admin)
Scott Wilson India Pvt.Ltd. New elhi-44

Subject: Request for withdrawal of Provident Fund Accumulations

Dear Sir,

I hereby request you to pay the full amount standing to my credit in the fund after making such deductions as may be
authorized under the income Tax Act 1961. My particulars are as below:

1 Name of the Member : SANJIB GOHAIN

2 Father’s/Husband’s Name : LATE HIREN GOHAIN

3 Employee’s Code No :

4 P.F Account No : DL-24895/310

5 Permanent Account Number (PAN) : AKXPG0481A

(MANDATORY)
6 Date of Birth : 2nd May 1971

7 Date of Joining : 20th February 2004

8 Date of leaving service : 31st March 2011

9 Reasons for leaving service : Terminated by Company after Completion of Project .

10 Full Postal address : Vill.-Bhogagaon, P.O. Pulibor, Dist.:-Golaghat, Assam-785621

11 Bank A/c No. : A/c No-10698179443 S.B.I. GOLAGHAT (CIF No-80554654071)

12 Bank Address : Kusal Path, New Amolapatty, Golaghat, Assam-785621

I declare that I have not been employed in any factory or other establishment to which the employees Provident Funds and
Miscellaneous Provisions Act, 1952 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.
I certify that the particulars given above are true to the best of my knowledge.

APPROVED

(SIGNATURE OF TRUSTEE) (SIGNATURE OF MEMBER)

Received From_____________________________________________________

A sum of Rs.___________________by cheque no_________________________

Dated________________towards full &final settlement of PF money with interest

Affix Rs. 1
Revenue
Stamp

DATED: _____________ (SIGNATURE OF MEMBER)

Note: In case the member is migrated from India for permanent settlement/taking up employment abroad, please furnish a copy of
visa Affix Re. 1 Revenue Stamp