ean Sas ol ck iaeranrinns sestere Resi iciigi ERE 13 Repustion ISSUED FREE OF CHARGE Tee 1958 qn 15 cde em qo gece OND 1958 gpd ogcioreg ot 15 gy Dov. mur CoowrughH ADsiss 601d THE EMPLOYEE’S PROVIDENT FUND ACT, NO. 15 OF 1958 “es” pinsG O96 /usPortb “Cx” /FORM “K” Lom ema) 1 qb una “PARTE ose B bn Danis edie! ead gS aren add siddenen DBs} ones! B DoslBis cow BPnB Bs 8282 Baran) so gh 48 ph BF aSpnamce, Garcon, nang on aoterbr aging ibe 38 4b aks, Dadant het Pans, ‘CLAIM nade under Section 260/ Ue Act by member ofthe fund ar beifis payable under Section 23 the Act (preadnar quer bce ees ie BB eHinactine Cog 69 EMER BES ee BOD Zed DOD: oa gad, Gata Seaimsag 6 yihRed am Pera donne aria Uawea dan) gues) god 9pnps ap (Tis claimstould be seat to the commissioner of Labour through He employer under whorn the member was ast employed) 1. enundonan.sensbndenbi ae sn ] FalNanco for J = = » fates stoteandiso tented Fall Nunc mer tat byte g miata yogth 9 Full Name’ member smasher A. eodtoomd| so taned ou! eet oo | (ecgiabeed eDarraivtovain beh) atheyp. prtrdefel Dit) Full Name of member's spouse (i masncu es eB mean ded } H20 mo ek ATHY Seredans da, sasha Bara ret neuumarsresscwnon Any natural dstinguiing marks of member sortaroad ems oaKsto. 8. Padssine? (orvatsu guostsn Bata dcosmnl © yiasontae Dakss Jos soanst Qeuadnapi) bata AB TAS poten e.giceyPew fe) geo Co sae S Faonadan iaguiaiPss Sp sy orihoue Da (2) Memberstup Numer under lastempoyer ten 08 A) yhas Donor daw idgriansoh Sy ster mycag Pan Gata ca ah mai Pghs ota Ser fab. wisi, xsb3 se Puoroph (8). Metabesship Number uid previous employers if ty. andthe date, Moath or yer of leaving such employer noua | 8 wrsrdmonst A penbea Ae amrgidiBningd a Su ‘Age and due of bith ef member 9. qUsest noltenr suey YRus Dain IA0 IY Hla Sih SHIEH BIE be Kb Date on winich emplaymont ceased under the last eapleyer WWsdios noBEe wcint long soate nog Son Seas.) Band Op head 41 rons VATE! 201 MEI 29 ih BF mag # meh LIAB Brine 10108 (Cause of cessation oF employment (vi the Act and Note at page 2) resktenc nas Nate and adi. the aa employerDEO HED So Dela / Sp gone_usron open afer Buss trot | PARTICULARS OF NATIONAL IDENTITY CARD S85 vetoes gain oe Gow) Dado atten ic eorte hor eae 82 Eos aBetod wr oakta 8 ‘Name appeatin’on National eagnfcest Boone 80 agin Wnty Gard Bown snyns dia hain Sanpreysior Js CEAD sr Ope pet aster cesta Bi Bde Derasdscs.c ve Inadditionto this 2copy forthe National density Card certified by the vente 2 . | ‘employer isannexed arto aca vitor acisn Bx} idemiy Cao J : - geen 80% pepeed Basin toe 1 Bowosaadunc Goreng Ag uy wANINL $OH Amexed? Date ot sve DED OLS GDC OA GEO CIOS wisi weT AG eoaITD GUGUMGAG LOD) FOR HOLDERS OF BANK ACCOUNTS 36 ins - 488 588/208 8e)2 a ponies ames «Oo i) ogi ovataler Oi) TpeorAccom Savings: Caren Account | Bane of Bank e@ene aaoe sava3 Be oun dn ‘Sccourt No Bank ranch gue equal aS mS Spm G4j00 HS BBO wSOn HEz adstow te OE] EO. pussy 4g words LP hres wopioneeng Dehn mde arbomeId ig (eean'aSe amigas rnp axOa rena aso Qo) Please order ihe cheque enabling credo be made 19 my Bank Account of tie aforesaid Bank Satosnd/eootatedeion to} ae | da} Same cf Neate 0 aoSes [ouwjee ay ouypee | Name Conificae 1, easing | Sise andina FD a Bouy/areas srespsys Guwr Namen Birth Certificate’ Marriage Conticae 2. doBe megtes eno oe: Dp mea ter acon ssebuny Sse) Namein National Wenity Card 3. "B'DB em ond me “I ussbragoiung Gum) Same in “B” Card (Membership Card) A. oe Sanaa 9. 7 SGa8S wquet os Dovins usfuas0 outs h coxdhe afte Oude Gime Namein EPF Account at Central Bank of Sri Lanka 0D oust ne Badeeste nfolerctest Coe eactton Ao EB md selomeckesnand ga Bute gSiiRe outs oiian Courdnayh ogee BRagd or 8.9 fOUD3 Lara amas wainhob ona [hereby cemity that names ahove mentioned are refferdto anc andite same person Signature of Employer eopafoaud / mertarded Enea Se soe! 2 we e giinRes Pot coaciGe gaa ayo wrrontast ae os ‘Thumb Marks of Member a nee coetases | esanbed eclonus eos7.6E opettes a8 gdetoned quis P ginSau fe QOALA a mxiDingeS ae wremtnegsan ‘anes yanjtiorfon gen Signature of witessto signature and Thumb Marks of Member) Bde D8, BOIIED BONE } Name, Designation and sahtess of witnessI] On emos (eeiiesivion 589 wOBdoi Be Go) I. g0 uns CarmariauisguarSonnad Grinsinn. Govssoriy mg) PART II (To be filled in by the Employer) cece - seers 888.. ay se axed guano utes meses |S DE | ABs OD : eS )68. nn ROPDD (ADEE OD) csc ne “ope cHbec8 osigo ce c28o Gods BIH Bh | qe CHOD qUonitm qigqed Sosaead | reward. oy fae Sped | Reed eo wcg8 oped 10 bm atcuad guns ne ecgd St fg30 280) ania alba rec mil | mde, Smad / mot Gam Bad eBatenasts § eam 2m dae ch) 96h OS. com Orsed Gam See 20 Sona! Boo Dated gees! ngD ct (02) eo88 * 8 (9) Ortewd ESO OB Bp | que Ogodes! | exd Had HE Po eDel ED "BT nBiesad east Quom Be FORE 300, aul genie adage enue G = So Send SHB dn eg Bede 99 Eu ged Arrest BID cE avs EDSD DOE. (03) gee perinen | coersew USER FURS GEES eEND, GRU food COTEEC aoe ayALD Or GOED epg done Da « cg eomnw ensue BX amekgorer a Tain bas sn meg sxe Gara Dag eesno7e" Quinsur IRI / nrg water) Su indeoourrent/ eBags" os au 108/310 Bopp 419 ns adev Ape /a ree Ogynb G09 nayPurQowern fied labors var). Bary g wieich Oar SSeoasbor 10 mt UM dx pces. rnempiipers Bard SaryPeloas3. Boencnngtsiprd/aboaternr) Barry kaa Sprevaseh yuyagh wkhe abby BCI Golones. Beg xm F wih 2.90) Danaazeh. 20 MIE MED coon rgb #haTu 0 921 GA 19056) UASU AUT APTLY. BLLUBBBN eter (hoes "9" 9) aub eben agIC GS Np MUCE Uo Ady "G” GenswAswUwce any Veter e pay Gpreaae). eek) Daeriniru fads cies pBLslea, mapas) Reurm ns Bheendbe wpa aba g 9 aig OSyeber veMADprenazssAgCUGSBinn Gover (03) edn epintar) crit yatehnaeis DereyPennes SNE Geer) ‘jug avIGugaiae ureressser BLED wwe : 5 Manager Suprerintndsa/ Proper of. sitatedat.. : : Ao boreby conifythar nt Membership Nunber a) wasemployed 3s. inthe above estate establishes ane Wat / si isatreniber othe Employes Provident fund, He/ She is ririne/Feaving employment for dhe reason stated in paragraph 10 of his/tirsiaie. ty ter contributions have been femited in fll to the Cental Bank and the last month's contributions were inladed the tu of the emuihaton forthe month of 20 (G2) teerty tha since te ubmisstonof te ast C (3) rete, the curation 2shownin Annee ‘D" below have been scored up othe date ofleaing retirement ane have been included inthe remitances made by mete the Central Bank on Account te Employes Provides Fund (03) The said member sngnedthe claim and affixed his! herthumi marks in my presence etiousstesnd g203 eis owe | Simaure Soamnsuresuaster Da ps8 Enmployer's Number Gs] 446 | Due. Bc 202 mB e20 gonna [ed [BeBd aes 8" GEE!" Goremntiy/ Annes ‘D" (eB 8 (3) tote Pedal op 8 ear Hentd ad mB cue Bee) eb 9 cFarrbS 0 mes Car nit Se ard ds NEIOUEL B34 SB IE9AN (Conuibatons sented to Cenal Baok after subnision of last C @) Return) edemaldnunis Cerstd po ctimansgos |] Garantandagnrhat user Bo. occsenstenns fnnyearfon Da} Ennphoye’s Reeisvaion Number Enploymens Number) Se onze ergo Senders Bove Men Tout Pate odd Berdgd suuipsne mesma han Fiergpd Sons.eel) pits cous! a DEN aged Fao ccdmomd oSo G Co) BN OREO OPP GEA" 8" eos" 8” Ord OatimieE eqns oo oo! eeedg GA S85!) Bem (m2 E880 caxm quis! 208d aC qade Oyws'e) 5: chon! 38 Dee dae pose gqnd cedm &D BA anfin wd ¢ ALd OS qQeo Be wae (2° 8" 78%, * ed “oy Qe atom 5 mgd Nits deen Le mysin® Con MBgbeicend "A" enh “8 eas tatine 88 BoM EOSEIEI 9) O0.8R8N"E ","8"."ED" oy aladeRUD aBeisin Om omded aan aed eof goer Oe FORO quest wd gideiS Odate ad ap) 2:3 quan" B 3 "025 Satta cates ya G cram On ByagQd gusta Ged aada qyein® 8 908-20 Bem Bad “BR” O95 Ema ase MB 909 DO SOarID nage ates See8 adiEsId cooce @) eB ade Bad ndy vom cod Gand eqpst Saul aye Ga0l, eB ade gen! pagDe Gi) gage ano qucin W9e ool co BOnd, Habarcsd ond FO mOgR Eden. omED BB GD : 356 wg, O25, ense® 08 agg mrbuxe0 end maarevs8O mBnd, asstinadsiged qugd oul ordaySed mp02¢ emredo! Bon SRE mikies SY 290 asin Biel ani cm mind mabisiessd MAIO HO.gy elon (Cee ensIT Pack Seo BODOS CAMS UnAvA a Danes sopa%e ondary in 1 RK) 16 614.5) moras’ malar Quang wh,hur ar8F iy 8209 935 dnBes “3” C) pavorg “VP 2°(C3)oRar7 3 HrE9 GRUM Osler Quang QALGAL NEMA adn Kaas a Sia axed. (APABAKE: QBN YAOaoss saa Wdinoret evan, 30411 15 wraiths BUNS IDL 46d B27 Neoen ssc eH Sores Stach 416 8 7sad Cans Sa" (A), “0” B). 9" (H) 9 sa sot a1 498 ar ep ILIUIL TENN OFT SEH aeD6H GIFS Gacteierepth."19™ (HH) otga1t eeiromtisd 31 oh Dammiach 2D (RP 8.9.0 Opinina Begs fu sear Dwaged, "Bs" (KY ebininbes ii apd urap her oPurrad FUR die Gelerd yew) 00) Baeverey Cap). snseh az0s 9°93 (C3) aon, 2EGaed crop. sp raFonerbatiew GotereaTarcriipenin Pevehbr20 Doser HHS 91559) 1 Dpgices Qenerndains Gores sherpa rag arsei Dasigid mares pS snaye sit unre San Gasoe 2 alam niny area #.srini olrenosDst Degkaih ani ovens. aay eu Bafa aa Fanaubsyres cnsueh eso Gacnggiis teh srcipr iar e~ 186, 4000 GF. Oa.repube)- Tsaappa Ise sDL wry Pansy Op nfs Herarwxordyh Pot Baring Sasiuled ayFeh wnevarh eis .DUTE Dyes w10M'L gpbars musDyryP a4 7e1ra uA. aIWO8 bs (onva,enauoFinssii0: 2 sine na. 84. RKeay JLT Dy 0133 013 Gar Desh. Instruction forthe Employers, O1. Chock shether Fah. yeo"s name given in “K" form and your “C” oF “C3” Retuin seat to the Central Bank tallies. (Spelling: ‘nd inttals are important) if there iS any discrepancy you should certify by a letter thatthe names refer to one and the same person © Check whether "A". "Band “HW” Cards have already been forward. Ifaot, complete them, check with “C” or °C3" Return and annex to application 03. G@)_ See that the ist month of conubution is Comeutly entered in part of °K" foam, (©) Ifyouhave sen conibation to Central Bank after submission of yourlist “C3” return, completethe“D” anne. Ensure that all pas °C3 returns have bec finished. Instruction for the Applicant (01, Completed °K" application should be submitted to the neareat District Labour Office or sub labour office, 02. Please attach the relevant documents as stated in the instruction form. weed comrbente! PnP qymrersorer Commissioner of Labour.