Date :-

/ 20

To,
The Trustees
ICICI Bank Ltd. Provident Fund
ICICI Bank Ltd,
Payroll Department
Trans Trade Centre,
5th Floor, Near Floral Deck Plaza,
Near Seepz, MIDC Andheri (E),
Mumbai 400 093.

Dear Sir,

Sub : Provident Fund Settlement

As I have resigned from the services of the Bank and not taken up any employment. I hereby
request you to settle my PF dues at the earliest.
I authorise you to deduct Income Tax, if any, payable on such withdrawal.
Thanking you,
Yours faithfully,
________________
( Signature )
Name :___________________________________________
Emp. No. :_____________ Date of Join. : _______________
Last Working Day : _______________________________
Address :__________________________________________
__________________________________________
__________________________________________
__________________________________________
Email ID. : ________________________________________
P.A.N. (Income Tax) *: ______________________________
* (Mandatory Attach copy of the P.A.N. Card)
Tel. No. : _________________________________________
ICICI Bank SB A/c No. :_____________________________

ADVANCE STAMPED RECEIPT

Receive with thanks from ICICI Bank Ltd. Provident Fund a sum of Rs.
_______________________

Rupees

___________________________

___________________________________________) vide Cheque No. _____________

dated ___________________ towards full and final settlement of all my Provident Fund
dues.

Rs. 1/Revenue
Stamp
_______________
( Signature )
Name :___________________________

Note : Kindly affix 1Rs. Revenue stamp, sign across and

send
the advance stamped receipt alongwith the form.