ONLINE TRANSFER CLAIM FORM [FORM 13 (REVISED) ]
( Tracking ID: 10161979102505002 )
Claim Date : 24/04/2025
EMPLOYEES' PROVIDENT FUND SCHEME, 1952
(PARA 57)
(This form has been printed on the basis of Online Transfer Claim Form filled up by the member under Unified Portal for submission to the
employer.)
To,
The Regional P.F. Commissioner,
RAIPUR (CHATTISGARH),
D-Block, Scheme No. 32, Indira Gandhi Comm.Complex,Pandri, Raipur
Sir,
I request that my Provident Fund balance along with my Pension Service Details may please be transferred to my present
account under intimation to me. My details are as under :
PART A : PERSONAL INFORMATION
1. Name : MONIKA VERMA
2. Mobile Number : 7880049068
3. E-mail id : -
4. Bank Account Number : 08533211112662
5. Bank IFSC : UCBA0000853
PART B : DETAILS OF PREVIOUS PF ACCOUNTS (WHICH IS TO BE TRANSFERRED)
1. PF Account No. (with EPFO : CGRAI14906390000010390
2. Name of the Establishment : SYNERGY HEALTHTECH
3. Address of the : RING ROAD NO.1, BESIDES AIRTEL OFFICE, TELIBANDHA ,RAIPUR
RAIPUR CH 495
4. PF A/C No. held by : RAIPUR (CHATTISGARH)
5. Name of the Trust : NOT APPLICABLE
6. PF A/C No. in Trust : NOT APPLICABLE
7. Bank A/C No. of Trust : NOT APPLICABLE
8. IFS Code of the Bank Branch of
Trust where : NOT APPLICABLE
9. Member's Name : MONIKA VERMA
10 Date of Birth : 05/08/1997
11 Father's/Spouse Name : GOVIND VERMA
12 Relationship : HUSBAND
13 Date of joining : 16/01/2021
14 Date of leaving : 30/06/2021
PART C : DETAILS OF PRESENT PF ACCOUNT
1. PF Account No. (with EPFO : CGRAI00219960000013041
2. Name of the Establishment : HEALTH-TECH CHHATTISGARH PRIVATE LIMITED
3. Address of the : SHREE NARAYANA HOSPITAL PREMISES, NEAR KRISHI UPAJ
MANDI,DEVENDRA NAG RAIPUR 495
4. PF A/C No. held by : RO RAIPUR (CHATTISGARH)
5. Name of the Trust : NOT APPLICABLE
6. PF A/C No. in Trust : NOT APPLICABLE
7. Bank A/C No. of Trust : NOT APPLICABLE
8. IFS Code of the Bank Branch of
Trust where : NOT APPLICABLE
9. Member's Name : MONIKA VERMA
10 Date of Birth : 05/08/1997
11 Father's/Spouse Name : GOVIND VERMA
12 Relationship : HUSBAND
13 Date of joining : 14/12/2021
I, Certify that all the information given above are true to the best of my knowledge and I have ensured the correctness of
my present and previous account numbers.
Signature of the member
