Form No 19
EMPLOYEE’S PROVIDENT FUNDS SCHEME 1952
FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEMES,1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES(PARA-72(5)).
(Note: Read the instruction carefully before filing this form)
(All correction/Alteration should be attested by the Employer)
1. Name of the Member (In block Letters) Mukesh Bhatia
Emp No _2072455
2. Parent Name (Husband’s name in case of the Ajay Bhatia married women)
3. Name and Address of the Factory/ Establishment in which the member was last
Employed
4. Code No & Account No.
5. Date of the Leaving Service
14 Oct 2009
6. Reason of the Leaving Service Resigned
7. Full Postal Address (In Block Letters) No 480 2nd Cross, Prestige Apartments
Please furnish correct address/information West of the chord Road, Rajajinagar Bangalore-560036
8. Mode of the Remittance
Put a ticket against the any one M.O CHEQUE
(A) By postal money order at my cost if the amount Payable exceeds Rs.500/(if the amount payable is Less than Rs.500/ M.O commission will be come by the PF Office. Payment Exceeds more then
Rs.2000 above will not made through M.O. to the address given in Item No 7 B By Account payee cheque send direct for credit S.B A/c no 0014690000321
for the SB A/c any Scheduled Bank/Post Office/
Co-operative Bank) under intimation to me E.C.S No
(Advance stamped receipt furnished below) Please furnish the S.B. A/c.No duly optioned in Name of the bank H D F C Bank any nationalized bank/Scheduled Bank/
Co-operative bank with the Full postal address Branch Alwarpet Branch
of the bank
Full Address of the Bank HDFC bank Brigade Mansion,Jeevan
Bheeema Nagar, Alwarpet Chennai-600012
CERTIFED THAT THE PATICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date of Birth/Age 12 .01.1983
For Office Use Only Inward No. Employee Number Name of the Employee Father’s /Husband’s Name
Will appix the company seal
KN/25075/40108
Last Working day
Leave blank Present Postal Address Bank Account Number Leave Blank Name of the Bank Address of the bank with the Pin address
Date of Birth PF Number
Date of Joining Establishment 10.03.2003 Date of Leaving Service 14.10.2009
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.
Date:
Signature of the Employer/ Signature/left hand thumb impression of the Authorized Official with rubber stamp Member
___________________________________________________________________________________________________________
Declaration of the Non Employment
Note : in the case of submission of application for settlement under clause (E) of sib paragraph (1) and in clause(2)of paragraph 69 of the EPF scheme 1952 , he claim should be submitted after two months from the date of
leaving service provided the member to remain un-Employed in an Est. to which the Act applies.
Date : Signature/left 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 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. The space should be left blank which shall be filled in by
Employer Provident Fund Office.
Signature/left hand thumb impression of the member on the Revenue Stamp
FOR THE USE OF COMMISSIONER’S OFFICE
Account settled in Part/Full entered in F.21/A/24/2/9 and withdrawal register
Clerk Section
Supervisor
__________________________________________________________________________________________________________ Under Rs.___________________________________________________________________________________________Only) P.I No__________________________M.O/Cheque_______________________A/c N KN/BN__________________________ Section ________________________________ Passed for Payment for Rs._________________________________(In Words) Rupess__________________________________________________________________________________________Only) M .O.Commission if any _______________________________________________Date____________________________ Net Amount to be paid by M.O_____________________________________________________________________
EE ER TOTAL
Interest up to Amount Authorized
Date : A.A.O/A.P.F.C FOR USE IN CASH SECTION
Paid in inclusion Cheque No ____________________________________________dated_____________________Vide cash Book (Bank)
Account No 3 Debit Item No.
C.W S.S AAO A.A.O/A.P.F.C
Remarks
Acknowledgment received on __________________________________________________Verified on____________________ Date of Joining
Date of Leaving
Signature of the Employee Signature of the central Spoc with the Authorization seal
Signature of the Employee
Affix Re.1/-Revenue
Stamp Signature of the
Employee (No need
to paste the revenue stamp)
Form No 10-C(E.P.S)
Employees Pension Scheme-1995
FORM TO USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME 1995 FOR
CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
(Read the instructions before filing this form)
1 (A) Name of the Member (In Block Letters)
(B)Name of the claimant (s)
2. Date of Birth
3 (A) Father’s Name
(B) Husband’s Name (If Applicable)
4. Name and Address of the Factory/Establishment in which the member was last Employee.
______________________________________________________ __________________________________________________________ 5.Code No & Account No RO/SRO CODE
EST. Code No A/ c no
KN/25075/40108
6.Reasons for Leaving Service Resigned
& Date of Leaving
7.Full Postal Address (In Block Letters) No 480 2nd Cross, Prestige Apartments
West of chord Road,Rajaji nagar Bangalore-560028
Sri/Smt/Kum S/o.D/o.H/o.W/o
8 Are you willing to accept Scheme
Certificate in lieu Withdrawal Benefits? (A) Yes (B) No
9. Particulars on Family (Spouse, Children or Nominee)
Name Date of Birth Relation with Name of the the nominee the minor (A) Family Member(s)
(B) Nominee Inward No: Mukesh Bhatia Name of the Employee Date of Birth
12
01
1983
Father’s/Husband’s NameAjay Bhatia Will appix the company
seal PF Number Date of Leaving 14 10 2009 Present Postal Address Put a right mark inside the box Leave blank
Leave Blank
10 Incase of Death of the member after the age of 58 years without filing the form.
(A) Date of the Death of the Member
(B) Name of the Claimant(s) and relation ship with the member.
____________________________________________________________ 11. Mode of the remittance (PUT A TICKET IN THE BOX AGAINST THE ON OPTION)
(A) By postal Money Order at my cost to the Address given in the Column 7
(B) Account payee cheque’s sent direct for to credit to my S.B A/c (Scheduled Bank to me under intimation to me
S.B A/c no 0014690000321 ECS Code No ____________________ Name of the Bank ( In Block Letters) H D F C Bank
Full postal address of the branch HDFC bank Brigade Mansion,Jeevan
(In Block letters) Bheeema Nagar, Alwarpet Chennai-600012
12 Are you availing under EPS-1995 If so Indicate
PPO No ____________________by Whom issued__________________________ ____________________________________________________________________________________________________________ ____
CERTIFED THAT PARTICULARS ARE TRUE TO THE BEST OF THE MY KNOWLEDGE
Date: Signature/left hand thumb impression of the member/Claimant(s)
ADVANCED STAMPED RECEIPT
(To be furnished only in case of 11 (b) above)
Received the sum of Rs.____________________________________(Rupees________________________________only)
From the Regional Provident Fund Commissioner/Officer –in-charge of Sub Regional Office, by depositing in my savings bank A/c towards the settlement of my Provident Fund Account.
The space should be left blank which shall be filled by this office
Signature/left hand thumb impression of the member on the revenue stamp
Put a right mark inside the box
Bank Account Number Leave blank
Name of the bank
Full Address of the bank Leave Blank Signature of the Employee Affix Re.1/-Revenue Stamp Signature of the Employee (No need to paste the revenue stamp)
Certified that the particulars of the member given are correct and the member has signed/thumb impression before me. The details of wages and period of non-contributory services of the member are furnished under Form- 3A/7(EPS) enclosed for the period for which was not sent the Employees Provident Fund Office
Date of Joining
Wages (Basic+D.A) As on 15/11/95 (if Applicable) Wages on the date of Exit
Period of Non-Contributory Services Y M D
Date Signature of the Employer/ Authorized official with Rubber stamp
(FOR THE USE IN COMMISSIONER’S OFFICE)
Under (Rs.____________________________P I No_________________________________ M.O.Cheque ____________________ Passed for the payment for Rs._________(Rupees)___________________________________________only)
M.O commissioner (If any) Rs.____________________net amount to be paid by M.O __________________towards withdrawal benefit.
D.A S.S A.A.O
Paid by inclusion in Cheque No___________________________________________date _________________vide Cheque Book Account No 10 Debit Item No______________________________________
D.A S.S AC (CASH)
For issues of S.S :IDS is enclosed
D.A S.S APFC (A/CS)
(FOR USE IN PENISION SECTION)
Scheme Certificate bearing the control no Issued on and entered in the scheme certificate control register
D.A S.S APFC (Pension)
