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FORM NO. 19
APPLICATION BY AN ADULT MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEME,
1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES
The Employees Provident Fund Scheme, 1952
[Para 69(2)9b)]
1.
2.
Fathers name (or husbands name in the case of a married woman) : H.K.
MAHAPATRA
3.
4.
5.
6.
7.
Full postal address (in BLOCK letters): Room No 248, Taksha Shila
Hostel,..
MDI, Sukhrali, Mehrauli Gurgaon Road, Gurgaon,
.
Haryana.Pin Code: ..122002Ph / Mob No:
..8010599607...
8.
Mode of remittance:
S.B. Accounts No. ______________________________________________
Name of the Bank ______________________________________________
(in block letters)
Full Address Of the Branch (in block letters) __________________________
______________________________________________________________
RTGS/NEFT IFSC Code__________________________________________
Note : Please attach a cancelled cheque along with the Form 19 (Mandatory)
(ADVANCE STAMPED RECEIPT FURNISHED BELOW)
Date:
Encl.: ..
Declaration of non-employment
I declare that I have not been employed in any factory/establishment to which the
Act applies for a continuous period of not less than 2 months immediately preceding
the date of my application for final withdrawal of my provident fund money.
Date: .
Affix
Re. 1
Revenue
Stamp
Guidelines
Emp. No.______________
Mob No. ______________
Serial No:
Form No. 10 C (E.P.S)
Sapient
Unitech Infospace
Building No-2, Tower-A
Region/SRO Code
Estt. Code No.
A/c No.
HR/GGN/
5. (a) Date of Joining the Estt. ________________ ______________
6. Reason for leaving service _____RESIGNED_________________
& Date of leaving_________________________________________
7. Full Postal Address :(In Block Letters)__________________________________________
___________________________________________
___________________________________________
PIN_______________ Phone No:_______________
(a)
Yes
(b)
No
Date of Birth
(a) Family
Members
(b) Nominee
10. In case of death of member after attaining the age of 58 years without filing the claim:(a) Date of death of the member:
(b) Name of the Claimant(s) / and relationship with the members:
11. 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)
Full Address Of the Branch (in block letters) __________________________
_____________________________________________________________
RTGS/NEFT IFSC Code__________________________________________
Note : Please attach a cancelled cheque along with the Form 10C (Mandatory)
Date ______________
Signature OR left
hand thumb
impression of the
member on the 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)
Basic Wages as on the date of exit Rs._________________
Period of non-contributory Service
Year/Month No.of days
Date
Signature of Employer/
authorised Official
D.H.
S.S
A.A.O
D.H
S.S
AC(A/cs)
S.S
A.A.O/APFC (A/cs)
D.H
D.H
S.S
A.A.O
APFC(PENSION)
Guidelines