CAPGEMINI INDIA PRIVATE LIMITED EMPLOYEES' PROVIDENT FUND

PLANT 2, BLOCK A , GODREJ & BOYCE COMPOUNT

GODREJ IT PARK, LBS MARG, VIKHROLI (WEST)
MUMBAI - 400 084

APPLICATION FOR ADVANCE FROM THE EMPLOYEES’ PROVIDENT FUND

Purpose for which advance is required : ________________________________________________________

Under PF Rule : ________________________________________________________

Amount of Advance Required : Rs.___________________/- ( In Figure)

In Words: Rupees ____________________________________

________________________________________________________

1) Name of Member : ________________________________________________________

2) Father's Name / Husband's Name in case of married women :

3) Name and Address of the Establishment : CAPGEMINI INDIA PRIVATE LIMITED

PLANT 2, BLOCK "A", GODREJ & BOYCE COMPOUND
GODREJ IT PARK, LBS MARG,
VIKHROLI (WEST), MUMBAI - 400 084.

4) Provident Fund Account No. : TH/THA/EXEM/43355/_____________

5) Monthly Basic Salary : Rs._________________/-

6) Full Postal Address : ________________________________________________________

(in block letters) ________________________________________________________
________________________________________________________

7) MODE OF REMITTANCE
a) In case of Advance for purpose of Site/House/Flat or
Construction through an “Agency” ‘or’ Repayment of housing
loan, indicate

i) in whose favour the cheque is to be drawn, and : ________________________________________________________

ii) Full Address of Agency : ________________________________________________________

________________________________________________________

________________________________________________________

b) In other Cases, tick any one of the following :

i) By account payee cheque :

ii) Bank Transfer :

Saving Bank Account No. : ________________________________________________________

Name of Bank : ________________________________________________________

Branch Name & Full Address : ________________________________________________________

I declare that the above particulars are true to the best of my knowledge and I will abide by the conditions governing the grant of advance
under the Scheme Certificates/ documents in support of my application is/ are furnished/enclosed.

Place : _____________
Date : _____________ Signature of Member
 CAPGEMINI INDIA PRIVATE LIMITED EMPLOYEES' PROVIDENT FUND
PLANT 2, BLOCK A , GODREJ & BOYCE COMPOUNT
GODREJ IT PARK, LBS MARG, VIKHROLI (WEST)
MUMBAI - 400 084

ADVANCED STAMPED RECEIPT

Received sum of Rs. _________________ /- ( Rupees________________________________________________________________only ) from

CAPGEMINI INDIA PRIVATE LIMITED EMPLOYEE'S PROVIDENT FUND towards the grant of advance from my Employees'
Provident Fund Account maintained by Trustees.

Affix Rs. 1/-

Revenue
Stamp

Signature of Member

DECLARATION & UNDERTAKING

( Fill the appropriate details, applicable)

A) Under Rule 19D : Applicable Not Applicable (Tick any one)

1)
I, Mr. /Ms._____________________________, hereby declared that Advance is required to meet the expenses in connection with my marriage
/ marriage of my son / daughter / brother / sister: Shri / kumari ___________________________________Age_____years to be celebrated on
____________ at ________________________.

B) Uner Rule 19A : Applicable Not Applicable (Tick any one)

1) I, Mr./Ms. ____________________________, hereby undertake that I have availed PF advance towards purchase of Plot / Construction / Flat
purchased on ___________________ bearing CTS No.…… situated at
________________________________________________________________________________________________________________
Furhter I hereby declare that the said property is occupied by myself or jointly owned with Spouse and I have no plan to sale out this
Property at least for the next 5 years.

2) I _____________________________________________s/o, d/o, w/o _______________________________________________

hereby solemnly declare that the information furnished above are true to the best of my knowledge and above mentioned * (dwelling site
or dwelling house/flat or house under construction ) is free from all encumbrances. I also declare that I am not purchasing a share in *
joint property or constructing a house on a site owned jointly except with the spouse. I undertake that the * house/site/flat is registered
in my name/ my spouse (name)________________________________________ (give name of * wife /husband / or jointly in the name of my
spouse _________________________________ (give name) and myself.

3) I hereby undertake to submit a copy of Registered * deed / allotment letter / possession memo / construction completion certificate
immediately on receipt/ completion / within one year whichever is earlier.

4) I also undertake to produce the above documents whenever demanded by the sanctioning authority for future verification.

5) I understand that as per the provision of Employees’ Provident Fund Scheme 1952,I am liable to refund the entire amount of withdrawal
in lump sum with penal interest in case the amount is used for any purpose other than the purpose stated in the application. I authorise
the Trustees of the Capgemini Consulting India Pvt. Ltd. Employees’ Provident Fund to recover the amount sanctioned with penal interest
@2% p.a. from my salary in case I fail to produce copy of the registered purchase * deed / completion certificate within * Three months
after the withdrawal of the amount, as the case may be.

C) Under Rule 19C : Applicable Not Applicable (Tick any one)

1) I, Mr. /Ms._____________________________, hereby declared that I am not enrolled under Employee's State Insurance Scheme.

D) Applicable to All availing Advance Withdrawal form Provident Fund

Further I declare that in case the amount is used for any purpose other than the stated above, I am liable to refund the entrire amount
with penal interest.

Place :
Date : Signature of Member