Max Financial Services Limited Employees' Provident Fund Trust
FORM 19 : PROVIDENT FUND SETTLEMENT APPLICATION
The Provident Fund Trustees
Dear Sir(s)
I hereby request you to pay the full amount standing to my credit in the fund after making such deductions as may be authorised under the Provident Fund Trust
Rules/Income Tax Act, 1961. My particulars are as below:
1 Name of the member : DEEPA
2 Father's Name : MADAN LAL
3 Husband's Name : ASHOK GUPTA
4 Employee's Code No. : HRY1477
5 Location/Unit : KARNAL
6 Universal Account Number (UAN) (12 digits) : 101820961325
7 PF Account Number : LDJAL00113320002468446
8 Aadhaar Number (12 digits) :
(Also enclose self-certified true copy of the Aadhaar)
984824249135
9 Permanent Account Number (PAN) :
(Also enclose self-certified true copy of the PAN Card) EFIPD3241H
10 Date of Birth (DD/MM/YYYY) : 22/01/1978
11 Date of Joining (DD/MM/YYYY) : 26/10/2022
12 Date of Leaving (DD/MM/YYYY) : 03/01/2024
13 Reasons for leaving service : CESSATION
14 Gender (Male/Female) : Female
15 E-mail id : deepa22011978@gmail.com
16 Mobile Number : 8607612333
17 Residence Phone Number with STD Code :
18 Nationality :
INDIAN
(in case of non-Indian, Please also enclose copy of Passport )
19 Complete Res. Address with PIN Code : HOUSE NO. 575, URBAN ESTATE, 13 EXTENSION, KARNAL, HARYANA, 132001
(Also enclose self-certified true copy of residential address proof)
20 Member's Saving Bank Number :
06810100019164
(Account should not be in Joint Name)
21 IFS Code of the Bank Branch ( 11 digits) : BARB0KARNAL
22 Name of Member's Bank : BANK OF BARODA
23 Address of Member's Bank with PIN Code : KARNAL BRANCH,OPP KARAN PARK, G T ROAD,,KARNAL,132001
(Also enclose one Original Cancelled Cheque Leaf)
24 *Enclose Self-certified true copy of Form 16 from the : Enclosed for the years:
date of joining to date of leaving, in case the 1 3 5
employee is having membership for less than 5 years
2 4
I declare that I have not been employed in any factory or other establishment to which the Employees' Provident Funds and Miscellaneous
Provisions Act, 1952 (PF Act, 52) applies for a continuous period of not less than 2 months immediately preceding the date of my
application for withdrawal of my provident fund money.
I hereby agree and undertake to keep you harmless and fully indemnified from and against all losses, cost or damages, which you may
suffer or incur due to my withdrawal of provident fund amount having being proved to be based on a false declaration at any time in
future.
Self-certified true copy of document(s) in support of my application is/are furnished/enclosed.
I certify that the particulars given above are true to the best of my knowledge.
Approved
Signature of Authorised Signatory
of Company with Stamp Signature of Member
Dated_____________
* To ensure tax deduction at appropriate rates, enclose Form 16 otherwise deduction shall be made at highest applicable rate.
* In case the member has migrated from India for permanent settlement/taking up employment abroad, please furnish a copy of visa.
