FORM C
[See sub-paragraphs (1) and (3) of paragraph 9]
STATE BANK OF .
Application form for withdrawals under the Public Provident Fund Scheme,1968

To
The Agent/Manager,
State Bank of .
1. I wish to withdraw from Public Provident Fund Account No. a sum of
Rs. (Rupees ). A period of years has expired
from the end of the year in which the initial subscription was made.
1A. I have not made any withdrawal in the current year.
2. Certified, that the amount sought to be withdrawn is required for the use of who is
alive and is still a minor.
3. The Pass Book is enclosed.
Date Signature or thumb impression of subscriber/guardian
Score out whichever is not applicable
TO BE USED BY THE ACCOUNTS OFFICE
A/c No. .
Date of initial subscription .
Amount available in the Public Provident Fund Account .
Date on which last withdrawal was allowed .
Amount available for withdrawal in accordance with para 9(1)/9(3) of the scheme
Withdrawal of a sum of Rs. sanctioned
Signature of Accounts Officer
Date .
Received a sum of Rs. (Rupees ) by way of
withdrawal from Public Provident Fund Account No. .
STAMP
Date .
Signature/thumb impression of
subscriber/guardian