CENTRAL PROVIDENT FUND BOARD APPLICATION TO WITHDRAW CPF UNDER THE GROUND OF LEAVING SINGAPORE AND WEST MALAYSIA PERMANENTLY under Section 15 of the Central Provident Fund Act (Chapter 36)

CPF-LM

79 ROBINSON ROAD, SINGAPORE 068897 TEL: 1800-227 1188 FAX:6229 3356 EMAIL:[email protected] Warning: It is an offence to make any false statement or to produce or furnish any document which is false for any purpose connected with this Act PLEASE READ NOTES ON PAGES 3 AND 4 COMPLETE THE FORM USING CAPITAL LETTERS ONLY (This form may take about 5 minutes to complete)

PART 1

SINGAPORE IC NUMBER OR CPF MEMBERSHIP NUMBER

PARTICULARS OF MEMBER: (as shown on the identity card or travel document)

NAME: *MR/MDM/MS ______________________________________________________________________________

*S/T DATE OF BIRTH ___________________________________ CITIZENSHIP __________________________________

MALAYSIAN IC NUMBER

PASSPORT NUMBER _________________________________________ DATE OF EXPIRY _____________________ LAST DATE OF EMPLOYMENT IN SINGAPORE ___________________________________ TELEPHONE NO. ___________________________ (SINGAPORE) INTERNET E-MAIL ADDRESS __________________________________________________________________________________________________________ OVERSEAS FORWARDING ADDRESS ___________________________________________________________________________________________________

_____________________________________________________________________________________ COUNTRY OF DESTINATION ____________________

PART 2 DECLARATION I declare that I am not a citizen of Singapore and that I *am about to leave/left Singapore and West Malaysia permanently on ____________________ with no intention of returning for further employment or residence. In accordance with Section 15 of the Central Provident Fund Act, I hereby apply to withdraw the whole sum standing to my credit in the Central Provident Fund. I further declare that I am not an undischarged bankrupt. I wish to receive the withdrawal payment: (please tick only one box) In Singapore Dollars through my bank account no.____________________________ with __________________________________________________ (Note: Bank account must not be a trust or fixed deposit account) (Name of Bank) at ____________________________________________________________________________________________________________________________ (Address of bank, including street name, building name & postal/district code)

** Swift Code : ______________________________________ by a CPF Withdrawal Cheque in Singapore Dollars to enable me to collect my CPF personally at the Board’s appointed bank in Singapore.

________________________________________ Right Thumb Print/Signature of Applicant

Date: ___________________________________

(If the application is completed outside Singapore, supporting documents should be certified true by a Notary Public or an Official from the Singapore High Commission or the Embassy of the Republic of Singapore with his official seal/stamp duly affixed)

FOR OFFICIAL USE ONLY PART 3

ACCEPTANCE AND VERIFICATION OF APPLICATION BY CUS/WSD COLLECTION OF PAYMENT

Accepted by

Date Date_________________

(Name of Officer)

Time _________________ AM/PM *

Income Tax Amount: Keyed by

Bank Account verified by

Claim Authorised By

Date of Processing

Code

ACKNOWLEDGEMENT OF PAYMENT

Remarks

Paid By :___________________

PART 4

DATE RECEIVED

PAYMENT DETAILS

Paid $________________________ by Cheque No.____________________________ Dated _____________ (Replaced by Cheque No._______________________________________ on __________________________)

Payment Officers •Delete whichever is inapplicable ** The swift code can be obtained from the bank.

1

(10/2005)

N.B. Application can only be submitted one month before date of departure from Singapore and West Malaysia and at least fifteen workings days’ notice is required before payment can be made. Amendments made must be signed against by the member. Use of correction fluid/tape is not allowed.

FOR OFFICIAL USE ONLY PART 5 CONFIRMATION OF BANK ACCOUNT

FOR BANK’S USE ONLY

We confirm that ……………………………………………………………………………………………………………………………………….. holder of (Name of Account Holder) *Singapore Identity Card / Malaysian Identity Card / Passport No. ……………………………………………………………………………. Maintains a …………………………….. account with us under account no. ……………………………………………………………………………………………... *(personal/joint) Name of Bank : ……………………………………………………………………………………………………………………………………………………. Address of Bank : …………………………………………………………………………………………………………………………………………………. (including street name, building name & postal/district code)

**Swift Code : …………………………………

Certified by Bank: …………………………………………………………..

………………………………………

Bank’s Stamp & Signature

Date

Note: The bank account must not be a trust account or fixed deposit account. PART 6

LETTER OF INDEMNITY TO BE COMPLETED IN THE PRESENCE OF A CPF BOARD’S OFFICER (not applicable if application is sent by post)

In consideration of the Central Provident Fund Board releasing to me at my request the CPF which I am entitled to withdraw from my CPF account no. ........................................................ with the Fund through my ……………………………. bank account no. ………………………………. *(personal/joint) with ............................................................... at..................................................................................................................................................………. (Name of Bank) (Address of bank including street name, building name & postal/district code)

I, ....................................................................................................................................……., holder of *NRIC No./Passport No. ................................. residing at ...................................................................................................................................................................................................................... (Address) hereby declare that I shall at all times hereafter indemnify the Central Provident Fund Board against all actions, proceedings, claims, damages, costs, expenses and any loss whatsoever which the Central Provident Fund Board may be liable to incur or suffer as a result of releasing such CPF to me through my aforesaid bank account.

.................................................................................... Signature or Right Thumb Impression of Member

......................................................................... Signature of CPF Board’s Officer

.................................................................................... Name & *NRIC No./Passport No. of Member

......................................................................... Name of CPF Board’s Officer

Date : ........................................................................ I confirm that the contents of the above Letter of Indemnity was interpreted and explained by me to the member in ................................................... *language/dialect which *he/she understands. The member acknowledged that *he/she understood the contents of the Letter of Indemnity and appended *his/her *signature/right thumb impression in my presence.

……………….......................................................................... Signature of Interpreter

……………….......................................................................... Name & *NRIC No./Malaysian IC No./Passport No.

Date : ........................................................................

•Delete whichever is inapplicable. ** The swift code can be obtained from the bank.

2

Amendments made must be signed against by the member. Use of correction fluid/tape is not allowed.

NOTES ON PROCEDURES FOR WITHDRAWAL If you are not a Singapore citizen and are about to leave or have left Singapore and West Malaysia with no intention of returning for further employment or residence, you may apply for the withdrawal of CPF. To enable the Board to process your application for withdrawal, you are advised to complete page 1 of this application form and forward it to the CPF Board together with certified true copies of all the relevant documents as required below. The photocopies of all such documents must be certified by a Notary Public or an official from the Singapore High Commission or the Embassy of the Republic of Singapore with his official seal/stamp duly affixed. Type of Applicant

A.

B.

Document Required

For an applicant who has renounced his Singapore citizenship to migrate to another country (other than West Malaysia).

1.

Foreign citizenship certificate, foreign passport or Singapore Certificate of Identity, showing the passport or Certificate of Identity number, your full personal particulars, your signature and the date of the expiry of the passport or Certificate of Identity.

2.

A letter of acknowledgement from the Immigration & Checkpoints Authority confirming the renunciation of your Singapore citizenship.

For an applicant who is not a citizen of Singapore or West Malaysia.

1.

Your passport, showing the passport number, full personal particulars, your signature and the date of the expiry of the passport.

2.

Evidence of cancellation of Work Permit and/or Employment Pass and/or Dependant Pass. (i)

If you were also a permanent resident of Singapore, please also produce the documents as specified in (D)

For a Work Permit Holder: (a) A letter of acknowledgement from the Work Pass Division, confirming the cancellation of the Work Permit. (b) Your Special Pass, issued by the Immigration & Checkpoints Authority, showing the date of the departure from Singapore.

(ii)

For an Employment Pass holder and/or a Dependant Pass holder: (a)

C.

For an applicant who is a Malaysian If you were also a permanent resident of Singapore, please also produce the documents as specified in (D)

Your passport, showing the cancellation of the Employment Pass and/or the Dependant Pass and/or the Dependant Pass and the multiple journey visa, and/or the amendment of the validity of the Employment Pass to the date of the departure from Singapore.

3.

CPF membership card (if any).

4.

Bank passbook/statement showing your name, bank account number and name of the bank.

1.

Your Malaysian identity card.

2.

Your international passport showing the passport number, full personal particulars, your signature and the date of the expiry of the passport.

3.

Evidence of foreign permanent residence status or citizenship.

4.

Evidence of cancellation of Work Permit and/or Employment Pass and/or Dependant Pass. (i)

For a Work Permit Holder: (a) A letter of acknowledgement from the Work Pass Division, confirming the cancellation of the Work Permit. (b) Your Special Pass, issued by the Immigration & Checkpoints Authority, showing the date of the departure from Singapore.

(ii)

D.

For an applicant who is a permanent resident of Singapore and is leaving or has left Singapore and West Malaysia.

For an Employment Pass holder and/or a Dependant Pass holder: (a)

Your passport, showing the cancellation of the Employment Pass and/or the Dependant Pass and/or the Dependant Pass and the multiple journey visa, and/or the amendment of the validity of the Employment Pass to the date of the departure from Singapore.

(b)

Your passport, showing a social visit pass valid for not more than 4 weeks. (This is only applicable to an applicant who is still in Singapore).

5.

A one-way air-ticket to the country of of your destination, if you are departing from West Malaysia.

6.

CPF membership card (if any).

7.

Bank passbook/statement showing your name, bank account number and name of the bank.

1.

As in (B) or (c) above.

2.

A letter of acknowledgement from the Immigration & Checkpoints Authority, confirming the cancellation of your Entry Permit and Re-entry Permit.

3.

CPF membership card (if any).

4.

Bank passbook/statement showing your name, bank account number and name of the bank.

3 Please note that you may be required to produce further evidence or supporting documents other than those as listed above to support your application.

METHODS OF PAYMENT If you wish the amount due to you to be credited to a specific bank account in Singapore Dollars, please furnish your bank account number on Part 2 of this application form. If you are submitting your application form personally at the CPF Office, please bring with you your original bank passbook for verification. If you are sending your application by post or through a representative, please attach a certified true copy of your bank passbook, showing your name and bank account number. The copy of the bank passbook must be certified by a Notary Public or an Official from the Singapore High Commission or the Embassy of the Republic of Singapore. Payments will be made to your bank account overseas by telegraphic transfer in Singapore Dollars. However, you will have to bear all the bank and commission charges and that your bank must accept the payment in Singapore Dollars for the crediting. In the event that a telegraphic transfer cannot be made to your bank account, a demand draft in Singapore Dollars will be sent to your address as indicated in Part 1. If the bank account number is not furnished on Part 2 of this application form, the payment will be made to you as follows:

1.

If you have not yet left Singapore A CPF Withdrawal Cheque in Singapore Dollars will be sent to advise you to collect the payment from the Board’s appointed bank.

2.

If you have already left Singapore A demand draft in Singapore Dollars will be sent to your address as indicated in Part 1.

CPF Offices 1.

Main Office 79 Robinson Road Singapore 068897 Tel: 1800-2271188

2.

CPF Bishan Office CPF Bishan Building 3 Bishan Place #01-01 Singapore 579838

3.

Woodlands Office 900 South Woodlands Drive Woodlands Civic Centre #01-02 Singapore 730900

4

4.

Jurong Office 21 Jurong East St 13 #01-01 Singapore 609646

5.

Tampines Office 1 Tampines Central 5 #01-01 Singapore 529508