Emp.

Code DL\937412\180

Emp. Mobile No:.. 09319245221

Employees Provident Fund Scheme

Form 19

Group 19
Paragraph 72(5) of Employees Provident Funds Scheme, 1952 Form to be used by a Major Member of Employees Provident Funds Scheme, 1952 for Claiming the Employees Provident Fund Dues : 1 2 3 4 5 6 7 Name of the member (in Block Letters)
(as appear in bank book/cheque attached)

ANANT BHARGAVA LT D.P.BHARGAVA

AMITY GLOBAL VARSITY (P) LTD
DL\937412\180

Fathers Name (or husbands name in the

case of married woman)

Name and address of the Factory/Establishment in which the member was last employed Account No(PF A/C No.) Date of leaving service Reason for leaving service Full Postal Address(Block Letters)

PERSONAL Father/Husbands name :LATE D.P.BHARGAVA

Mr./Mrs
Address

ANANT BHARGAVA

16/82 SHEETLA GALI, NEAR PHULLATI BAZAR AGRA Pin Code 282003 Put a Tick in box against the one opted

Mode of Remittance

(a) by postal money order at my cost (b) By A/C payee cheque sent direct to my S.B. A/c

To the address given against item no.7

S. B. A/C No
(As shown in cheque)

08422151001613

( ) S. B A/c details as follows IFS Code

(As shown in cheque)

ORBC0100842

Bank Name

Branch Name

ORIENTAL BANK OF COMMERCE

SANJAY PALACE

Complete Address of Bank

PRINCE TOWER, SANJAY PALACE, AGRA

Pin Code 282002

(Advance Stamped Receipt furnished below) Certified that the particulars are true to the best of my knowledge. Date of Joining the Establishment Date of Birth

09-11-2013 23-07-1987
Month. Contribution.. Period Employee Employer Total of break if any EPF FP EPF FP EPF FP

Contribution for the current financial year Month. Contribution.. Period Employee Employer Total of break if any EPF FP EPF FP EPF FP

Form 3A enclosed

(Information tobe furnished by the employer if the claim form attested by the employer) Certified that the above contributions have been included in the regular monthly remittance. The applicant has signed/thumb impressed before me.

X Signature of the employer or authorised Official

Declaration of Non employment Note: In case of submission of application for settlement under clause (s) of Sub-paragraph (i) and in clause (b) of sub paragraph (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 continue to remain unemployed in an est. to which Act applies. X

Signature of left/right Thumb impression of the member

Signature of left/right Thumb impression of the member

Advance Stamped Receipt Received a sum of Rs____________/-(Rupees______________________) from Regional Provident Fund Commissioner/ Officer-inCharge of Sub-Regional Office______________ deposit in my Savings Bank Account towards the settlement of Provident Fund Account. * The space should be left blank which shall be filled in by Regional Provident fund Commissioner/Officer-in-charge of S.R.O.

Affix 1 ruppes Revenue Stamps

Signature of left/right hand thumb impression of the member (For the use of Commissioners Office) A/c. settled in part/Full Entered in F-21-A/224/29 Withdrawal Register. Clerk Head Clerk (P.I. No.) .. (M.O./Cheque)..Account No. (Section). Under Rs. Passed for Payment of Rs. . in words) M.O. Commission If any) Net Amount to be paid by M.O. Accounts Officer Date ..

Paid by inclusion in Cheque No. dt..Vide Cash Book (Bank) Account No. 10 Debit Item No. .. H.C.
Remarks Acknowledgment Card Account No. Acknowledgement Received the following claims. EPF FPF IF Registration No. . Date Office Seal.. EPFO Office of the RPFC/Officer-in Charge of Sub-Regional Office

AC/RC

In case, no intimation is received within a Month, you may write to the complaints Officer, Employees Provident fund duly quoting the Registration Number and your Provident Fund Account Number . . PIN Employees Provident fund Organisation Office of the Regional Provident Fund Commissioner/ S.R.O. .. (Full Address).