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    2 views2 pages

    PF Form - PDF 1

    Uploaded by

    garvmonu

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 2
    baa wate 4 wan fey qo Ho For Office use only. Regd. No. arfert affea—fate atorn,1952 EMPLOYEES' PROVIDENT FUND SCHEME, 1952 5Ta—19 Form—19 are cor ter FAR oT aren GRA TTT ante wf A eines anf Gee aT I OTT Form to be used by a major member of the Employees’ Provident Fund Scheme, 1952 for claiming the Employees’ Provident Fund dues [Para 72] (5)} (arm “agen” td) a 1, Wee wT AT (eae seal A) Name of the member (in block letters) 2, PRT a TH aT GAR eT ATH Pet Ret & RS A) Father's Name (or husband's Name in the case of ‘married women) 3. Fag wT ATA a eT free eee orem are Pega fart mar on | Name and Address of the Factory/Establishment which the member was last employed, 4. een io Account No. PN/HR 5. tod vist A AE Date of leaving Service 6. Aad Uist 1 ore Reason of leaving Service 7, Wa OER Full postal address (in block letters) AAA ShrilSmtKumari we GA S SioNWio (Dio. Pin No. 8. pra wh Re ain find oo ws w Frese Ra ae Mode of Remittance Put a ‘Tick’ in Box against the one opted (eR at ade re fe re vio 7 fq me mw {2} Bypotal gear anes (3 To the address given against item No. 7 ‘aia eo i} aaa 4 aren wo Seeches A tanita Gas () ‘te wT sre eer @ Sa Oe | wel oR om (©) By account payees cheque sent 8.8. AccountNo. Director credit to my S.B. Nameofthe Bank. NG (Scheduled Bank/P.O.) Branch under intimation fo me. FullAddress ofthe Branch: (atin eae arti ete ara gt) (Advance Stamped Receipt furnished below) ser Fr aren fr et oa a ge Sete Peet Crt that he particular ao rue to the Best of my knowledge eer tes oh A Date of ining the Establishment conf awa sin, cone ee Contibvgn ire Guest Financial Yer ae ere eer A sre eT sae eraurt BA safe aft aig A at aft wie At Month Conuilen __ Part Beak any Menh___Contouion _ Pes of rakit any tet] tte |g win | tte |e - ewptovee lewprovens| Toma | ge enplovee [ewpLovens| TOTAL Ee] mma l= fil 8] wanes [eam [aa [war [oe foam | oe] FS| vases [enm [ae [warm [aa foam [at cpr | er | evr | re [err | FP cpr |r | cor | er [err | FP a7 7 = ae/| ay PS Ww aes7 4 eee a7 sae] = et ie re asl Wo Ho 6/P.T.0. (af ren srr Paar ren rent Fen ren & at ae aT Pca Tet aT) (information tobe furnished by the Employer if the Claim Form is Atested by the Employer) so fen cen Fs eee keer Pre es oT er a 1 Certtied that the above contributions have been inlidedin the regular monthly remittances melt 9 a any weer fussy arent ‘The Applicant has signed/thumb impressed before me ISAT BH RRMA SHIT AT /ATG Te B SFIS ar Pra FAR/Date. rene ‘Signature or Left/Right hand thumb impression of the member ears otk Aree Designation & Seal SIMA / Encl atl 8 EY EWN Declaration of non-employment fecwh : GoHoho chorat 1952 ter 69 Tater (2) ws (w) ate a—Her (1) B as (e) S ora era S arg mete we wrt Haren hang TSA aH ae a Sh AeA w are RT wT MH Ae MTT TTT. ‘aerorere er Bh rere eH ger Hore wh ArT oe HAP a] TB Note: Inthe case of submission of application for settlement under clause (s) of sub-paragraph (i) andin clause (b) of sub paragraph (2) of paragraph 69 of the EPF Scheme, 1952 theclaim shouldbe submitted aftertwomonths trom the date of leaving service provided the member continues to remain un-employed in an est. to which the Act applies. weer & ramen sera aay are & sys wr PraTT fAR/Date. as ‘Signature or Left/Right hand thumb impression of the member caf Rave ah eae (Gert uct « (@) B ATS A wee aA UIT) ADVANCE STAMPED RECEIPT (To be furnished only in case oft) above) orator PAR organ mee wae afer re te FT TA frre eo) ae ah ee ts ea A Receivedasumot “Rs. 4{Rupees..... Regional Provident Fund Commissioner/Oicerin-Charge of Sub Regional fice...

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