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PF Form 19 & 10C (Speciman Copy)

PF Form 19 & 10C (Speciman Copy)

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Published by: teniya on Jul 24, 2012
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05/07/2015

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Regn. No.

…………………………

EMPLOYEES’ PROVIDENT FUND SCHEME, 1952
(Refer to Instruction)

Form 19

For Office use only

Application by an Adult Member of the Employees’ Provident Fund Scheme, 1952 for Claiming the Employees’ Provident Fund Dues

Name of the member (In Block Letters)

AAAA

2. Father’s Name or (husband’s name in the case of married woman) BBBBB Name & Address of the Factory/ Establishment Genpact India, DMRC, IT Park , Shastry Park, New Delhi - 110053 in which the member was last employed 4. PF Account No. DL/20846/3987

3.
In

5. Date of leaving service 6. Reason for leaving service

10-Sep-2003 RESIGNATION Shri/ Smt. Kum. : ……………………………………………………………………………. S/o. W/o., D/o: …(Complete Mailing Address) ………………………………………………………. Pin: ……………………………………………………………………….

7. Full Postal Address (in Block Letters)

Put a tick (4 ) in the box against one opted To the address given against item No. 7. S.B. Account No. ……………………………………. Name of Bank/Branch ……………………………… …………………………………………………………. Full address of the Branch ………………………… …………………………………………………………. Certified that the particulars are true to the best of my knowledge. Date of Joining the Establishment ……17-May-2000…………………………………………………………………………………….. Date of Birth ……………………………………………………….. Contribution for the Current Financial Year Sl. Month Wages Contribution Period of Break, No. if any Employee Employer Total EPF EPS EPF EPS EPF EPS

8. Mode of remittance (a) By Postal Money Order at my cost (b) By Account payee cheque sent Direct for credit to my S.B. A/c (Schedule Bank/PO) Under intimation to me

( ( ( (

) ) ) )

Clerk …………………………………………………… (under Rs. M.C.. The Applicant has signed / thump impressed before me.) Head Clerk P.. …………………… in wards …………………………………………………………………………………………………………………………..O.. Account No. ……………………………………./ Cheque ………………………………………………………. By deposit in my Saving Bank account towards the settlement of my Provident Fund Account (Sign) Signature of left / Right hand thump impression of the member (For the use of Commissioner’s Office) A/c Settled in part/Full Entered in F..) From Regional Provident fund Commissioner / Officer-in Charge of Sub-Accounts Office ………………………………. / passed for payment of Rs.. (For use in Cash Section) Paid by inclusion in Cheque No. ………………………………………………………………. No. (Sign) Signature of Left/ Right hand thump impression of the member Signature of the Employer or authorized Officer Designation & Seal: Date : ………………………. Commissioner (if any) AAO/APFC ………………………………… Account Officer …………………………………… Net Amount paid by M. Vide cash Book (Bank) Account No.(Information to be furnished by the Employer if the Claim Form is Attested by the Employer) Certified that the above contributions have been included is the regular monthly remittances.I. M. Remarks AC/RC . ……………………………Section ………………………….21-A/24/2/9 & withdrawal register.O. 3 Debit Item No. (Rupees ………………………………………………………. ………………………………………………………………… date …………………………. ………………………………………………… H.. (Sign) Date : ……………………… Signature of Left/Right hand thump impression of the member ADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above) Received a sum of *Rs... ……………………………………………………. …………………………………………………………………. 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 proceeding the date of my application for final withdrawal of my Provident fund money.O. Date ……………………………….

Full Postal Address (In Block Letters) Sh. the member was last employed 6. ……………………………………………………………………. ……………………………………… PIN ………………………….FORM 10-C (EPS) EMPLOYEES’ PENSION SCHEME. 4. Reason for leaving service & Date of leaving . Smt. Genpact India -----------------------------------------------------------------------------------------------------------------------------------------------------------------Region / SRO Code DL/20846/6987 Estt. BBBBB ……………………………………………………………………. 3. A/c No. 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE 1. 10. S/o.. ……………………………………………………………………. (a) Name of the member (In Block letters) (b) Name of the claimant(s) 2. Code No. W/o. Code No. Km. D/o Complete Mailing Address ………………………………………………………………………. Date of Birth Father’s Name Husband’s Name (If applicable) …………AAAAA………………………………………………… AAAA ……………………………………………………………………. 9. ………………………………………………………………………. Sep-2003 ……………………………………………………………………… ……………………………………………………………………… 8. Name & Address of the Establishment in which. Resignation. 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME. Are you willing to accept Scheme Certificate in Lieu of withdrawal benefits (a) Yes (b) No(Please tick No) 5. 7. & Account No.

indicate PPO No. ………………………………………By whom issued …………………………. Certified that the particulars are true to the best of my knowledge. Name of the guardian of minor …………………………………… …………………………………… Family Member Nominee …………………………… …………………………. Mode for Remittance [Put a Tick in the Box against the one opted] (a) (b) By Postal money order at my cost to address given against item No. In case of death of member after attaining the age of 58 years without filing the claim: (a) (b) Date of death of the member Name of the Claimant(s) / and relationship with the member …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… 12.. …………………………………………………………………………………………… …………………………………………………………………………………………… ……………………………………………………………………………………………. (a) (b) 11. Complete address of the Branch in which the account is held ……………………………………………………………………………………………. 13... ………………………………. (Sign) Signature or Left Hand Thump Impression Of the Member / claimant(s) Date: ………………… ……… .. Particulars of Family (Spouse & Children & Nominee) Name Date of Birth ……………. 7 Account payee cheque sent direct for direct to my SB A/c (Schedule Bank) Under intimation to me. Relationship with member ………………………………. Are you availing pension under EPS – 95? Not Applicable If so. ……………. Name of the Bank (in block letters) Branch (in block letters) Full address of the Branch (in block letters) 111111111111111 ………………………………………………………………………………………… ICICI Bank …………………………………………………………………………………………… Name of the branch …………………………………………………………………………………………….B. S...10. Account No.

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.95 (if applicable) Wages as on the date of exit. Signature of Employer/ Authorised Official .Regional Office ……………………………… ………………………………………………………. Period of non-contributory Service Year / Month No. (The Space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer-in-charge) (Sign) Rs.ADVANCE STAMPED RECEIPT [To be furnished only in case of 12 (b) above] Received a sum of Rs.. 1/Revenue Stamp Signature or Left Hand thump Impression Of the Member on the stamp Certified that the particulars of the member given are correct and the member has signed / thump impressed before me.11. Wages (Basic + D.) only from Regional Provident Fund Commissioner / Officer – in – charge of Sub.A) as on 15. of days Date: ……………………………. By deposit in my savings Bank A/c towards the settlement of my Pension Fund Accounts. …………………… (Rupees ……………………………………………………………….

. and entered in the Scheme Certificate Control Register. AC (A/cs) D.. S.S. Passed for payment for Rs.S. S.. D.A.H.S. No. Dt.S. D./APFC (A/cs) (For use in Pension Section) Scheme Certificate bearing the control No. …………………………… issued on ……………….O. A. (For use in Cash Section) Paid by inclusion in cheque No.H.O. M. towards withdrawal benefits.A. ……………………………… vide cash Book (bank) Account No.I.O.H. ……………………………………………… ( in words) ……………………………… ……………………………………………………………………………………………………………………………… ………..O.H. APFC (PENSION) . …………………..: IDS is enclosed. / Cheque.S. ………………………………………………………………………………………………………………… P. A.O. ………………………………………… M. A. S.(FOR THE USE OF COMMISSIONER’S OFFICE) Under Rs.O. For issue if S. Commission (if any) …………………………………………………net amount to be paid by m.A. S. 10 Debit item No. ……………………………. …………………………… D.

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