PERMOHONAN PEMBATALAN PENGELUARAN KWSP
WITHDRAWAL CANCELLATION APPLICATION WDW 004
SILAGUNAKANPENDAKWATHITAM SAHAJADANPENGGUNAANCECAIRPEMADAMTIDAKDIBENARKAN
(A)MAKLUMAT PEMOHON / APPLICANT’S PARTICULARS
1. NO. AHLI KWSP 2. NO. MyKad - -
EPF MEMBERSHIP NO. MyKadNo.
3. N OTO HE. RP IE DEN NG TIFE ICN ATA IOL NA DN O CD UMIR EI N TL NA OI .N K POA LID CE K AUU TA HOS RA IT YP CO ARL DIS M Myy TeT ne ten ratera P PAA SSS PP OO RTRT NO.:
4.NAMA PENUH
FULL NAME
5. JENIS PENGELUARAN (TIDAK TERPAKAI BAGI PERMOHONAN PENGELUARAN PELABU-
TYPE OF WITHDRAWAL RAN AHLI /NOT APPLICABLE FOR MEMBERS INVESTMENT WITHDRAWAL APPLICATION)
6. SEBAB PEMBATALAN
PENGELUARAN AHLI TELAH MENINGGAL DUNIA
REASON FOR WITHDRAWAL MEMBER HAS PASSED AWAY
CANCELLATION
AHLI TELAH MEMBATALKAN PEMBELIAN RUMAH
MEMBER HAS CANCELLED THEIR HOUSE PURCHASE
PINJAMAN PERUMAHAN TIDAK DILULUSKAN
HOUSE LOAN FACILITY WAS NOT APPROVED
AHLI MEMILIH JENIS PENGELUARAN LAIN/ TIDAK INGIN MENERUSKAN PENGELUARAN
MEMBER HAS OPTED FOR ANOTHER WITHDRAWAL/ NO LONGER WISHES TO PROCEED WITH THE WITHDRAWAL APPLICATION
AHLI MEMBUAT LEBIH DARIPADA SATU PENGELUARAN PADA SATU MASA
MEMBER APPLIED FOR MORE THAN ONE WITHDRAWAL CONCURRENTLY
AHLI TIDAK INGIN MENERUSKAN PENGELUARAN
MEMBER NO LONGER WISHES TO PROCEED WITH THE WITHDRAWAL APPLICATION
LAIN-LAIN (NYATAKAN)
OTHER REASON (PLEASE ELABORATE)
(B)PENGESAHAN PEMOHON /DECLARATION BY APPLICANT
1.SAYA MENGAKU TANDATANGAN INI ADALAH MILIK SAYA DAN DENGAN MENANDATANGANI BORANG INI SAYA BERSETUJU UNTUK MEMBATALKAN
PENGELUARANSEPERTIYANGDINYATAKANDIATAS./ICONFIRMTHATTHISSIGNATUREBELONGSTOMEANDIAGREETOCANCELTHEWITHDRAWALASSTATED
ABOVEUPONSIGNINGTHISFORM.
2.PERSETUJUANINIMEMBATALKANPERMOHONANPENGELUARANYANGDINYATAKANDIATASSEKIRANYABELUMDILULUSKAN./IAGREETHATTHEWITHDRAWAL
STATEDABOVE,IFITHASYETTOBEAPPROVED,SHALLBECANCELED.
CAP IBU JARI (KIRI) / CAP IBU JARI (KANAN) /
THUMB PRINT (LEFT) THUMB PRINT (RIGHT)
TANDATANGAN PEMOHON
APPLICANT’S SIGNATURE
TARIKH PERMOHONAN (HH-BB-TTTT) - -
DATE OF APPLICATION (DD-MM-YYYY)
UNTUK KEGUNAAN KWSP SAHAJA/FOR EPF USE ONLY
TARIKH TERIMA(HH-BB-TTTT) - -
RECEIPT DATE (DD-MM-YYYY)
NO. ANGGOTA
STAFF NO.
CAWANGAN
BRANCH OFFICE
CAP TERIMA / STAMP OF RECEIPT
Untuksebarangpertanyaan: LamanWeb RasmiKWSP / EPF Official Website: www.kwsp.gov.my V20240228
For any inquiries: PusatPengurusanPerhubunganKWSP / EPF Contact Management Centre :03-8922 6000 KWSP WDW 004) 1/1