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Mobile Number

, 1952

EMPLOYEES PROVIDENT FUNDS SCHEME.1952


-19 / Form-19
1.

/ Name of the member

2.

( / a) / Fathers Name

3.

( / b) / Husbands Name
/ Date of Birth

( / a):

( / b):

/ / Name and Address of the Factory /


Establishment

( / a): . / P.F. Account No.

( / a):

( / b): (...) /Universal Account Number(UAN)

( / b):

.....................................................................................
6

/ Date of Joining the Establishment

/ Date of leaving Service

/ Reason of leaving Service


-

() () /
( ) ,
Service terminated on account of (a) ill health of member (b)
Contraction /Discontinuation of employers business or (c) Other
Cause beyond the control of the member

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/ Personal Reasons

* . ( )
....................................................................................................

*Permanent Account No.(PAN)


* 15 / 15

( / )

* Whether submitting Form No. 15 G/15 H , if applicable

(Yes/No)

....................................................................................................

15 / 15 , ( )
Please enclose two copies of Form No. 15G/15H, if applicable

* 5 /Only in case of service less than 5 years


10

- / Full Postal address


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Pin ..............................

11

/ Mode of payment:

/Saving Bank Account No.

( )
Put a Tick against the one opted

......

( )

()

(a)

By Postal Money Order at my cost

()

(b)

By Account Payee Cheque/ Electronic Mode of payment


Name of Bank

OR


Address of the Branch .

( / Please attach a copy of cancelled


Cheque/Attested copy of first page of Pass Book )

( / )

.......................................................................

. .
IFS Code

/ The member hereby declares that he has not been employed for two months (Yes/No.)

/ Certified that the particulars are true to the best of my knowledge.


/ / The Applicant has signed/thumb impressed before me.

/ Members Signature

/ Employers Signature

/ Or / Members thumb impression

/ Designation & Seal of Employer


/ Date ...............................

/ Enclosures:

( 11 ()
ADVANCE STAMPED RECEIPT (To be furnished only in case of 11(b)above)

`................................................................
Received a sum of `...from Regional Provident Fund Commissioner by deposit in my Saving Bank account towards the settlement of my Provident Fund
Account .

Affix Re 1/- Revenue


stamp & signature/thumb
impression

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/ ( For the use of Commissioners Office)
21 /2 / 3 ... 9 ( )
Account settled in Part/Full Entered in F-21-A/2 and Withdrawal Register / Form 3 (F.P.F.) Form9 (Revised)

... / SSA

. . / SS

P.I. No.

M.O./ Cheque

Account No.

/ Passed for payment for

` :.

... /TDS Rate %:

... / TDS Amount ` :.


... / Amount after TDS ` :.

( ) / M.O. Commission( if any)

/ Net Amount to be paid by M.O.

Accounts Officer

/ Date :

( ) / ( FOR USE IN CASH SECTION)


Paid by cheque NoDate Vide cash book

-10 ....................................................................................
And Account No.10 Debit item No.

--------------------------------.. / SS -------------------------------------------------------------------------------------- ./ A.PFC.--------------------------------------- / REMARKS

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Claim ID/ .. (for official use/ )