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    of 1

    Submitted online at UAN e-seva portal on 2024-05-31 09:26:41 (IP Address:47.11.78.85) www.epfindia.gov.

    in

    deZpkjh Hkfo"; fuf/k ;kstuk] 1952


    EMPLOYEES' PROVIDENT FUND SCHEME,1952
    EMPLOYEES' Pension Scheme,1995
    UAN Based Combined Claim Form 19/10C WB/31 for Advances/PF Final Settlement/Pension Fund Withdrawal
    (mu ekeyksa esa ykxw tgka QkeZ 11(u;k)esa deZpkjh dk iwjk fooj.k] vk/kkj la[;k vkSj cSad [kkrk la[;k ;w-,-,u- iksVZy vkSj ij
    miyC/k gS rFkk ;w-,-,u- esa lfØ; gSA)
    (Applicable in cases where employee's complete details in Form 11(New),Aadhaar Number and Bank
    Accounts details are available on UAN Portal and UAN has been activated.)
    Mobile Number / eksckby uacj - 9547815246
    1. I want to apply for PF Advance
    2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 101457980268
    3. Name of the member AJAY BOURI

    4. Date of Joining 02-May-2023


    5. Permanent Account number / LFkk;h [kkrk la[;k EPQPB8357J

    6.a Purpose of Advance Illness

    6.b Amount of Advance (In Rs) 11500


    7 In case of Advance for purpose of Site/House/Flat Not Applicable

    8 Bankers details for Electronic Payment (Only for the Advance if payable to Not Applicable
    third party)

    9. Payee Address Bauri para,Sadhuna Samdi


    ,salanpur,Asansol,BARDDHAMAN,WEST
    BENGAL-713359

    Father/Husband/Spouse Name: SARAT BAURI Date Of Birth: 06-Apr-1994


    Bank Account Number 34386521329 Bank IFSC Code SBIN0002114
    Bank Details STATE BANK OF INDIA,RUPNARAINPUR
    Aadhaar 35XXXXXXXX96
    Member ID WBCAL16678500000023614
    *Certified that the particulars are true to the best of my knowledge, I certify that I have gone through the data
    seeded in UAN portal and found all data, including Form No 11 (New), Bank Account details and Aadhaar number to
    be correct. Please make the payment in the bank account mentioned in the UAN Portal. A cancelled cheque
    (containing member's name, bank account number and IFS Code) is attached herewith. In case the amount is used for
    any purpose other than stated in column (6) above, I am liable to return the entire amount with penal interest.
    * —i;k ;w-,-,u-iksVZy ij n'kkZ, x, cSad [kkrs esa Hkqxrku djsaA
    * Please make payment in the bank account mentioned in the UAN portal .
    * The bank kyc has been online verified by bank and has been digitally signed by the employer for this case among
    other validations and therefore mandatory uploading of the image of cheque leaf/attested bank passbook is not
    required.

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