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    Form 19 10c With Instruction161

    Uploaded by

    RahulRanjan
    The form collects personal information of the member such as name, father's name, address, account number, reason for leaving employment, and bank account details. It asks if the member is willing to accept a scheme certificate in lieu of withdrawal benefits and collects details of family members and nominee. The member certifies the details are true and selects their preferred mode of payment/remittance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form 19 10c With Instruction161

    Uploaded by

    RahulRanjan
    56 views6 pages
    The form collects personal information of the member such as name, father's name, address, account number, reason for leaving employment, and bank account details. It asks if the member is willing to accept a scheme certificate in lieu of withdrawal benefits and collects details of family members and nominee. The member certifies the details are true and selects their preferred mode of payment/remittance.

    Original Title

    Form 19 10c With Instruction161 (1)

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    The form collects personal information of the member such as name, father's name, address, account number, reason for leaving employment, and bank account details. It asks if the member is willing to accept a scheme certificate in lieu of withdrawal benefits and collects details of family members and nominee. The member certifies the details are true and selects their preferred mode of payment/remittance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    56 views6 pages

    Form 19 10c With Instruction161

    Uploaded by

    RahulRanjan
    The form collects personal information of the member such as name, father's name, address, account number, reason for leaving employment, and bank account details. It asks if the member is willing to accept a scheme certificate in lieu of withdrawal benefits and collects details of family members and nominee. The member certifies the details are true and selects their preferred mode of payment/remittance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 6

    Regn. No ..

    PF Code ____________

    E Code _____________

    Mobile No
    Personal Email ID

    ____________________
    ____________________

    Employees Provident Fund Scheme, 1952


    Form 19
    (Refer to Instructions)
    1
    Name of the Member (in block letters)
    2
    Fathers Name (or Husbands Name
    in the case of married woman)
    3
    Name and address of the Factory/
    establishment in which the member
    was employed
    4
    Account No.
    5
    Date of leaving service
    6
    Reasons for leaving service
    7
    Full Postal address (in Block letters)

    Resignation
    Shri/Smt/Kumari
    S/o d/o w/o

    Pin
    Put a tick ( ) in the box against the one opted

    Mode of Remittance

    (a)
    (b)

    By Postal Money Order at my cost


    By account payee cheque sent
    Direct for credit to my S.B
    A/c (Scheduled Bank/P.O.)
    Under intimation to me

    (
    (

    )
    )

    To the address given against item No. 7


    S.B. Account No
    Name of the Bank
    Branch
    Full address of the Branch

    (Advance Stamped Receipt furnished below)


    Certified that the particulars are true to the best of my knowledge
    Date of joining the Establishment __________________________
    Date of Birth
    __________________________
    Contribution for the current financial year
    Month
    Month

    Wages

    Contribution
    Employee
    EPF
    FP

    Employer
    EPF
    FP

    Period of
    Break if any
    Total
    EPF
    FP

    Month
    Month

    Wages

    Contribution
    Employee
    EPF
    FP

    Employer
    EPF
    FP

    Period of
    Break if any
    Total
    EPF
    FP

    PF Code ____________
    (Information to be furnished by the Employer if the Claim Form is Attested by the Employer)
    Certified that the above contributions have been included in the regular monthly remittances.
    The applicant has signed / thumb impressed before me.

    Signature or Left/Right hand thumb impression of the member


    Date ________________________
    Designation & Seal ___________
    Encl
    Declaration of Non-employment
    Note : In the case of submission of application for settlement under clause (s) of sub-paragraph (i) and in clause (b)
    of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1952, the Claim should be submitted after two
    months from the date of leaving service provided the member continues to remain unemployed in an
    establishment to which the Act applies.

    Date:

    Signature or Left/Right 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 ________________________________________ only) from


    Regional Provident Fund Commissioner/ Officer-in-charge of Sub-Accounts Office ____________________________
    by deposit in my Savings Bank account towards the settlement of my Provident Fund Account.
    Affix 1/Rupee
    Revenue
    Stamp

    The space should be left blank which shall be filled


    in by Regional Provident Fund Commissioner/Officer
    in-Charge of S.A.O.

    Signature or Left/Right hand thumb impression of the member


    (For the use of Commissioners Office)
    A/c. Settled in Part/Full Entered in F.21-A/24/219 & Withdrawal register.
    Clerk
    Section Supervisor
    P.I.No.
    MO/Cheque
    Account No.______________ Section__________ Passed for Payment for Rs. ___________
    (In words ________________________)
    M.O Commissioner (if any)
    AOC./ APFC.
    Net Amount to be paid by MO Rs.
    Date

    (For use in Cash Section)


    Paid by inclusion in Cheque No. __________________________________ dated ___________
    vide Cash Book (Bank) Account No. 3 Debit Item No. __________________________________

    HC

    AC / RC
    Remarks

    E Code ____________

    PF Code ____________

    Serial No:

    For Office Use Only


    In Words No.

    Mobile No
    ______________
    Personal Email ID _________________

    Form No 10 C (EPS)

    EMPLOYEES PENSION SCHEME, 1995


    FORM TO BE USED BY A MEMBER OF THEEMPLOYEES PENSION SCHEME,
    1995 FOR CLAIMINGWITHDRAWAL BENEFIT/ SCHEME CERTIFICATE
    (Read the instructions before filling up this form)
    1

    a)
    b)

    Name of the member


    ( in block letters )
    Name of the claimant(s)

    Date of Birth

    a) Fathers Name
    b) Husbands Name (if applicable)

    Name & Address of the Establishment in


    which, the member was last employed

    Code No. & Account No

    Region/SRO Code
    Estt. Code

    Reason for leaving service


    & Date of leaving

    Full Postal Address


    (in Block letters)

    Resignation

    Sh/Smt./Km
    S/o, W/o, D/o
    PIN

    A/c No.

    PF Code ____________
    8.

    9.

    Are you willing to accept Scheme


    Certificate in lieu of withdrawal benefits

    (a)
    Yes

    (b)
    No

    Particulars of Family (Spouse & Children & Nominee)


    Name

    Date of
    birth

    Relationship with
    member

    Name of the Guardian Name


    of the Guardian

    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 claimant (s)/ and relation-ship with the member

    11.

    MODE OF REMITTANCE [PUT A TICK IN THE BOX AGAINST THE ONE OPTED]

    a)

    By postal money order at my cost to the 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. Account No
    Name of the Bank (In block letters)
    Branch (In block letters)
    Full Address Of the Branch (In block letters)

    12.

    Are you availing Pension under EPS, 1995?


    If so, Indicate PPO No. __________________ By whom issued ____________________

    CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

    Dated .
    Signature or left Hand Thumb impression of the member/Claimant(s)

    PF Code ____________

    ADVANCE STAMPED RECEIPT


    [To be furnished only in case of (b) above]

    Received a sum of Rs. ________________ ( Rupees ______________________________


    _____________________ only) from Regional Provident Fund Commissioner/Officer-in-charge of
    Sub-Regional Office, _________________________ by deposit in my Savings Bank A/c towards
    the settlement of my Pension Fund Account.

    (The space should be left blank which shall be filled by Regional Provident Fund Commissioner
    / Officer-in-charge)

    Signature or left hand thumb impression of the member on the stamp


    Re. 1
    Revenue
    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 3-A/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)

    Wages as on the date of exit

    Period of non-contributory service


    Year/Month

    No.of days
    Signature of Employer/
    Authorised Offical
    with seal

    Date:

    PF Code ____________
    ( FOR THE USE OF COMMISSIONERS OFFICE )

    ( Under Rs. ___________________________________________________________________


    P.I. No. _____________________________________________________ M.O. / Cheque

    Passed for payment for Rs. ____________________(in words)__________________________


    ___________________________________________________________________________________
    M.O. Commission (if any) __________________ net amount to be paid by M.O. ___________________
    towards withdrawal benefit.

    D.H.

    S.S.

    A.A.O

    ( FOR USE IN CASH SECTION )

    Paid by inclusion in cheque No. _______________ Date ___________ vide cash Book (Bank) Account
    No. 10 Debit item No. ____________________________

    D.H.

    S.S.

    AC(A/cs)

    For issue of S.S.; IDS is enclosed.

    D.H.

    S.S.

    A.A.O. / APFC(A/cs)

    ( FOR USE IN PENSION SECTION )

    Scheme Certificate bearing the Control No. __________________ issued on ____________ and
    entered in the Scheme Certificate Control Register:

    D.A.

    S.S.

    A.A.O.

    APFC(PENSION)

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