For Office Use Only Inward No:

Employees' Provident Fund Scheme, 1952

Form - 19
1. Name of the members in Block Letters 2. Parent Name (Husbands Name in the case of married woman) 3. Name & Address of the Factory/Establishment in which the member was employed. 4. Code No & Account No 5. Date of leaving service 6. Reason for leaving service 7. Full Postal Address (in Block Address) Shri/Smt./Kum : : : : : : : __________________________________ ___________________________________ ___________________ PIN NO._________ 8. Mode of Remittance
Cheque)

: By Cheque (Enclose the Cancelled/photo copy of

S.B Account No. Name of the Bank Branch Full Address of the Bank

: __________________________________ : __________________________________ : __________________________________ : __________________________________ ___________________________________ _______________PIN. No._____________

Date of Birth Date of Joining the Establishment Date of leaving service

For

: : :
.,

Signature of the Member/Employee Authorised Signatory

Note: In case of submission of application for settlement under clause (e) of sub-paragraph (1) and in clause (2) of paragraph 69 of the EPF Scheme, 1952, the claim should be submitted after two months from the date of leaving service provided the member continues to remain un-employed in as estt. To which the Act applies.

ADVANCE STAMPED RECEIPT Received a sum of Rs.*.. (Rupees* from the Regional Provident Fund Commissioner / Officer-in-charge of Sub Regional Office .. by deposit in my savings Bank Account towards the settlement of my Provident Fund Account. Signature of the Member/Employee FOR THE USE OF COMMISSIONER`S OFFICE
Account settled in Part/Full entered in F.21 A/24/2/9 and withdrawal register

Clerk

SS

Under Rs. ..only) P.I No .M.O/Cheque .A/c. No. KN/BN/ Section .Passed for payment for Rs. (in words) Rupees .. M O Commission if pay . Date Net Amount to be paid by M.O. EE Interest up to Amount Authorised Date: A.A.O./A.P.F.C ER Total

FOR USE IN CASH SECTION Paid by inclusion in cheque No. .Date.vide Cash Book (Bank) Account No.3 debit item No. C.W. A.A.O A.P.F.C./R.P.F.C REMARKS Acknowledgement received on .Verified on.. S.S.

Form 3A (Revised) Account No. KN/BN/ 16733/ Employees Share Month March paid in April May June July August September October November December January February Feb. paid in March Suppl.( if any) Total Amount of Wages E.P.F EPF Cont.(-) Pension Fund Cont. Pension Fund

for the year ____________

2. Name of the Employee_____________________________________ Employers Share Refund of Adv. Period of Break Remarks

Certified that the total amount of Contribution indicated in this card has already been remitted in full

For
Date: Authorised Signatory For Office Use only EMPLOYEES' SHARE Cont. Withdrawals OB

.,

Month OB April May June July August September October November December January February March Total

EMPLOYERS' SHARE Cont.

Withdrawals

AAO/APFC Dealing Clerk Section Supervisor

FORM NO. 10 C (E. P. S)

EMPLOYEES PENSION SCHEME 1995
FOPR TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE 1. (a) Name of the Member (in Block Letters) (b) Name of the claimant(s) 2. Date of Birth 3. (a) Fathers Name (b) Husbands Name (if applicable) 4. Name and Address of the Establishment in which the member was last employed 5. Code No. & Account No. 6. Reasons for leaving service & Date of leaving 7. Full Postal Address : : : : : : - NA -

: : __________________________________ : : ________________________________________ _________________________________________ _________________________________________ __________________ PIN NO._______________

Are you willing to accept Scheme (a) Yes (b) No Certificate in lieu of Withdrawal benefits? 8. Particulars of Family (Spouse, Children or Nominee) Name (a) Family Member(s) Date of Birth Relationship with the Member Name of the guardian for minor

(b) Nominee

9. In case of death of the member after attaining the age of 58 years without filing the claim: (a) Date of death of the Member (b) Name of the Claimant(s) and relationship with the member 10. MODE OF REMITTANCE (a) By postal money order at my cost to the address give against column No. 7 : : NA

NO
YES (Enclose the Cancelled/Photocopy of Cheque)

(b) Account payee cheque sent direct for credit to my : S.B. A/c (Scheduled Bank) under intimation to me S.B. Account No. Name of the Bank (in Block letters) Branch (in Block letters) Full Postal address of the Bank (in Block letters)

: _______________________________________ : _______________________________________ : ________________________________________ : ________________________________________ ________________________________________ ________________________________________ _______________________Ph . No.___________

11. Are you availing pension under EPS 1995? if so, indicate

PPO No.

by whom issued

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date:

Signature of the Member/Claimant(s)

12. ADVANCE STAMPED RECEIPT (To be furnished only in case of 11 (b) above) Received a sum of Rs.* ______________ (Rupees_____________________________________________only) From Regional P.F Commissioner/Officer in Charge of Sub Regional Office/Sub Account Office_______ by deposit in my savings bank A/c towards the settlement of my pension Fund Account. *The space should be left blank which shall be filled by Regional Provident Fund Commissioner/Officer in - Charge Signature of the Member 13. ATTENTION OF EMPLOYER / AUTHORISED OFFICIAL Certified that the particulars of the Member Sri/Smt./Kum ________________________ A/c_______________ are correct and the member has signed before me. The details of wages and period of non contributory service of the member are furnished under (Form 3A/7(EPS) enclosed for the period for which it was not sent to Employees Provident Fund Office. Date of Joining to the Estt. Wages (Basic+D.A) as on 15-11-95 (if applicable) Wages on the date of exit Period of non contributory service Date: For Authorised Sigantory
.,

: : : :

(FOR THE USE IN COMMISSIONER OFFICE) Under Rs. __________________________ P . L No.----------------------MO/Cheque______________________ passed for the payment__________Rs. __________________( in words in Rupees____________________________________________________________________ only) M.O. Commission ( if any) Rs._________ net amount to be paid by M.O _______________towards withdrawals benefits. __DA_____________________________SS_______________________________AAO__________________

FOR USE IN CASH SECTION Paid by inclusion in cheque no. __________ date____ vide cash Book ( Bank Account No. 10 debit item No._______________________________

DA

SS

AAO

AC(CASH)

For issue of SC IDS is enclosed with Form 2 revised

DA

SS

AAO APFC(A/c) ( FOR USE IN PENSION SECTION)

Scheme Certificate bearing the control No._______________________ issued on _________ and entered in th Scheme Certificate Control Register

DA

SS

AAO

APFC(Pension)