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
Reason for leaving
Mention the 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 your postal address 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
Code *Branch Name
Fill above Information as they are mandatory *
Employee needs to sign here
* 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 4th 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
