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 Name of the
Emp No _2072455 Employee
Father’s /Husband’s
2. Parent Name (Husband’s name in case of the Ajay Bhatia Name
married women)

3. Name and Address of the Factory/

Establishment in which the member was last Will appix the company
Employed seal

4. Code No & Account No. PF Number

KN/25075/40108

5. Date of the Leaving Service Last Working day

14 Oct 2009

6. Reason of the Leaving Service Resigned Leave blank

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 Present Postal
Address

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 Bank Account
by the PF Office. Payment Exceeds more then Number
Rs.2000 above will not made through M.O. to the address given in Item No 7
Leave Blank
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/ Name of the Bank
Co-operative Bank) under intimation to me E.C.S No Address of the
(Advance stamped receipt furnished below) bank with the Pin
Please furnish the S.B. A/c.No duly optioned in Name of the bank H D F C Bank address
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
Date of Birth/Age 12 .01.1983
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/-
The space should be left blank which shall be filled in by Revenue
Employer Provident Fund Office. Stamp Signature of the
Employee (No need
Signature/left hand thumb impression of the
to paste the
member on the Revenue Stamp
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)

Name of the
1 (A) Name of the Member (In Block Letters) Mukesh Bhatia Employee

(B)Name of the claimant (s)

Date of Birth

2. Date of Birth 12 01 1983 Father’s/Husband’s

Name
3 (A) Father’s Name Ajay Bhatia 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 RO/SRO CODE
EST. Code No A/ c no
KN/25075/40108

PF Number

Date of Leaving
6.Reasons for Leaving Service Resigned
& Date of Leaving
14 10 2009
Present Postal
7.Full Postal Address (In Block Letters) No 480 2nd Cross, Prestige Apartments Address
West of chord Road,Rajaji nagar
Bangalore-560028
Sri/Smt/Kum Put a right
S/o.D/o.H/o.W/o 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 Date of Birth Relation with Name of the

the nominee the minor

(A) Family Member(s)

(B) Nominee
 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 Put a right
(B) Account payee cheque’s sent direct for mark
to credit to my S.B A/c (Scheduled Bank inside the
to me under intimation to me box

Bank Account Number

S.B A/c no 0014690000321

ECS Code No ____________________ Leave blank

Name of the Bank ( In Block Letters) H D F C Bank Name of the bank

Full postal address of the branch HDFC bank Brigade Mansion,Jeevan

(In Block letters) 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/- Signature of
Revenue the Employee
Stamp (No need to
paste the
revenue
stamp)
Signature/left hand thumb impression of the member on 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 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)