PF Withdrawal Application (Sample Copy)

Form No 19 For Office Use Only Inward No. 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) Employee Number 1. Name of the Member (In block Letters) Mukesh Bhatia Emp No _2072455 2. Parent Name (Husband’s name in case of the married women)

Name of the Employee Father’s /Husband’s Name

Ajay Bhatia

3. Name and Address of the Factory/ Establishment in which the member was last Employed 4. Code No & Account No.

Will appix the company seal PF Number

KN/25075/40108

5. Date of the Leaving Service

6. Reason of the Leaving Service 7. Full Postal Address (In Block Letters) Please furnish correct address/information

8. Mode of the Remittance Put a ticket against the any one (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. B By Account payee cheque send direct for credit for the SB A/c any Scheduled Bank/Post Office/ Co-operative Bank) under intimation to me (Advance stamped receipt furnished below) Please furnish the S.B. A/c.No duly optioned in any nationalized bank/Scheduled Bank/ Co-operative bank with the Full postal address of the bank

Last Working day

14 Oct 2009 Resigned

Leave blank

No 480 2nd Cross, Prestige Apartments West of the chord Road, Rajajinagar Bangalore-560036 Present Postal Address

M.O

CHEQUE

to the address given in Item No 7 S.B A/c no 0014690000321 E.C.S No Name of the bank H D F C Bank

12 .01.1983

Leave Blank Name of the Bank Address of the bank with the Pin address

Branch Alwarpet Branch 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

Bank Account Number

Date of Birth

Date of Joining Establishment

10.03.2003

Date of Joining

Date of Leaving Service

14.10.2009

Date of Leaving

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me. Signature of the central Spoc with the Authorization seal

Signature of the Employee

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 Signature of leaving service provided the member to remain un-Employed in an Est. to which the Act applies. the Employee 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. Affix Re.1/Revenue Stamp

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

Signature of the Employee (No need to paste 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____________________

Form No 10-C(E.P.S) Employees Pension Scheme-1995 Inward No:

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)

Name of the Employee

Mukesh Bhatia

(B)Name of the claimant (s)

Date of Birth

2. Date of Birth

12

01

3 (A) Father’s Name

Ajay Bhatia

1983

Will appix the company seal

(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

Father’s/Husband’s Name

______________________________________________________ __________________________________________________________ RO/SRO CODE EST. Code No A/ c no KN/25075/40108 PF Number

6.Reasons for Leaving Service & Date of Leaving 7.Full Postal Address (In Block Letters) Sri/Smt/Kum S/o.D/o.H/o.W/o

Date of Leaving

Resigned 14

10

2009

No 480 2nd Cross, Prestige Apartments West of chord Road,Rajaji nagar Bangalore-560028

Put a right mark inside the box

8 Are you willing to accept Scheme Certificate in lieu Withdrawal Benefits?

(A) Yes

(B) No Leave blank

9. Particulars on Family (Spouse, Children or Nominee) Name (A) Family Member(s) (B) Nominee

Present Postal Address

Date of Birth

Relation with the nominee

Name of the the minor

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

____________________

Put a right mark inside the box

Bank Account Number Leave blank Name of the bank

Name of the Bank ( In Block Letters) H D F C Bank Full postal address of the branch (In Block letters)

HDFC bank Brigade Mansion,Jeevan Bheeema Nagar, Alwarpet Chennai-600012

Full Address of the bank

Leave Blank 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 Signature of the Employee 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 Affix Re.1/Revenue Stamp

stamp

Signature/left hand thumb impression of the member on the revenue

Signature of the Employee (No need to paste the revenue stamp)

Leave page blank

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

Date

M

D

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)

S.S

APFC (A/CS)

For issues of S.S :IDS is enclosed D.A

(FOR USE IN PENISION SECTION) Scheme Certificate bearing the control no scheme certificate control register D.A

Issued on S.S

and entered in the APFC (Pension)