Regn. No ..................................
Mobile Number..
Employees' Provident Fund Scheme, 1952
Form-19
(Refer to instruction)
1. Name of the members in Block Letters.
2. Father's Name or (husband's Name in the case of married woman)
3. Name & Address of the Factory/Establishment
in which the member was employed.
4. EPF Account No. - UP/28474/
5. Date of leaving service
6. Reason for leaving service
Shri/Smt./Kum ...........................
7. Full Postal Address (in Block Address)
S/O/W/O/D/O ............................
Pin :
Put a tick ( ) in the box against the one opted
8. Mode of remittance
(a) By Postal Money Order at my cost.
To the address given against item No. 7
(b) By account payee cheque sent
Direct for credit to my S.B.
A/c (Scheduled Bank/P.O.)
Under intimation to me.
S.B. Account No .........................................
Name of the Branch ....................................
Branch.......................................................
Full address of the branch...........................
(Advance Stamped Receipt furnished)
Certified that the particulars are true to the best of my knowledge.
Date of joining of Establishment .......................................................................
Date of Birth ..................................................................................................
Contribution for the Current Financial Year.
Month
Employee
Month
Contribution
Period of
break if any
Employers
Total
Month
Employee
Wages
Month
EPF
FP
EPF
FP
EPF
FP
Contribution
Period of break
if any
Employers
Total
Wages
EPF
FP
EPF
FP
EPF
FP
( information to be furnished by the Employer if the Claim Form is Attested by the Employer)
Certified that the above contributions have been included in the regular monthly remittances.
The Applicant has signed/Thumb impressed before me.
Signature of Left/Right hand thumb impression of the member
Date....................................
Designation & Seal
Encl.
Declaration of non-employment
Note:-
In the 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 continues to
remain unemployed in an establishment to which the Act applies.
Date .........................
Signature or Left / Right hand thumb impression of the member
ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above)
Received a sum of Rs ......................... (Rupees ....................................................................................... from
Regional Provident Fund Commissioner / Officer-in-Charge of Sub-Accounts Office ..............................................
by deposit in my Savings Bank account towards the settlement of my Provident Fund Account.
The space should be left blank which shall be filled
in by Regional Provident Fund Commissioner/Officer
in-Charge of S.A.O.
Affix 1/- Rupee
Revenue
Stamp
Signature or Left / Right hand thumb impression of the member
(For the use of Commissioner's Office)
A/C Settled in part/Full Entered in F. 21-A/24/219 & withdrawal register.
Clerk
Section Supervisor
P.I.No.------------------------------------------------------------------------- M.O./Cheque ---------------------------------Account No. ----------------------------- Section
------------------------ passed for payment for Rs.------------------in words)------------------------------------------------------------------------------------------------------------------------------M.O. Commission (if any) AOC/APFC----------------------------------Net Amount to be paid by M.0Date..
(For use in Cash Section)
Paid by inclusion in Cheque No .............................................................. date ..............................................
vide Cash Book (Bank) Account No.3 Debit Item No ...............................................
HC
AC / RC
Remarks
Serial No:
For Office Use Only
In Words No.
Form No. 10 C (E.P.S)
EMPLOYEES' PENSION SCHEME, 1995
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME,
1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
(Read the instructions before filling up this form)
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 & Address of the Establishment
in which, the member was last employed
5.
______________________________
Region/SRO Code
Code No. & Account No.
Estt. Code No.
6.
Reason for leaving service
& Date of leaving
A/c No.
______________________________
______________________________
7.
Full Postal Address :(In Block Letters)
Sh/Smt./Km
S/o, W/o, D/o
___________________________________
___________________________________
___________________________________
___________________PIN_____________
8.
Are you willing to accept Scheme
(a)
Certificate in lieu of withdrawal benefits
9.
(b)
Yes
No
Particulars of Family (Spouse & Children & Nominee)
Name
Date of Birth
Relationship With Member
Name of the guardan of minor
(a)
Family
Members
(b)
Nominee
10.
In case of death of member after attaining the age of 58 years without filing the claim:(a)
(b)
11.
Date of death of the member :
Name of the Claimant(s) / and relationship with the members :
MODE FOR REMITTANCE [PUT A TIC IN THE BOX AGAINST THE ONE OPTED]
(a)
By postal money order at my cost to address given against item No. 7
(b)
Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation
to me
S.B. Accounts No.
______________________________________________
Name of the Bank
(in block letters)
Branch
(in block letters)
Full Address Of the Branch
(in block letters)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
12.
Are your availing pension under EPS-95 ?
If so indicate
PPO NO._________________By Whom Issued______________
Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Signature or left Hand
Thumb Impression of the
Member / claimant(s)
Date ______________
ADVANCE STAMPED RECEIPT
[To be furnished only in case of (b) above]
Received a sum of Rs.(Rupees.) Only
from Regional Provident Fund Commissioner /Officer-in charge of Sub-Regional
Office___________________
by deposit in my savings Bank A/c towards the settlement of my Pension Fund Accounts.
(The Space should be left blank which shall be filled by Regional Provident Fund Commissioner /Officer-incharge)
Signature & left hand thumb impression of the member on the stamp
Rs 1/Revenue
Stamp
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.
The details of wages and period of non-contributory service of the member are as under:-
Form 3A/7 (EPS) enclosed for the period for which it was not sent to employees Provident Fund Office)
Wages (Basic + D.A) as on 15.11.95(if applicable)
Wages as on the date of exit
Period of non contributory Service
Year/Month
No.of days
Date
Signature of Employer/
authorised Official
(FOR THE USE OF COMMISSIONERS OFFICE)
(Under Rs P.I. No
M.O./Cheque
Passed for payment for Rs. (in words)..
.
M.O. Commission (if any)net amount to be paid by M.O towards
withdrawal benefit.
D.H.
S.S
A.A.O
(FOR USE IN CASH SECTION)
Paid by inclusion in cheque NoDt..vide cash Book(Bank) Account No. 10
Debit item No.
D.H
S.S
AC(A/cs)
S.S
A.A.O/APFC(A/cs)
For issue if S.S;. IDS is enclosed.
D.H
(FOR USE IN PENSION SECTION)
Scheme Certificate bearing the control No..Issued on ..and entered
in the scheme Certificate Control Register-
D.H
S.S
A.A.O
APFC(PENSION)
