eksckby la-@ Mobile Number

nkok la[;k@Clam I.D

dsoy dk;kZy; esa iz;ksx ds fy;s@ For Office use only

deZpkjh Hkfo;&fuf/k ;kstuk] 1952

EMPLOYEES PROVINDENT FUND SCHEME. 1952
izi=&19@ Form -19
;g QkEkZ Hkfo; fuf/k dk nkok djrs le; deZpkjh Hkfo; fuf/k laxBu ds ckfyx lnL; }kjk Hkjk tk,
From to be used by major member of the Employees Provident Fund Scheme, 1952 for claiming the
Provident Fund dues [Para72] (5)]
izi= Hkjus ls igys funsZkksa dks i<s+a@(Read the instructions before filing up this form)
1-

4-

lnL; dk uke LiV v{kjksa esa

Name of the member (in block letters)
firk@ifr dk uke fookfgr efgykvksa ds ekeys esa
Fathers/ husbands Name in the case of
married women
QSDVh@LFkkiuk dk uke o irk ftlesa lnL; vfUre
ckj fu;qDr fd;k x;k Fkk@Name and Address of
the Factory /Establishment in which the
member was last employed.
[kkrk la-@Account No.

5-

ukSdjh NksM+us dh frfFk/Date of leaving Service

6-

ukSdjh NksM+us dk dkj.k@Reason of leaving

Service
i= O;ogkj dk iwjk irk
Full postal address (in block letters)

23-

7-

Jh@Jhefr@dqekjh@ Shri/Smt./Kumari ..........................................................

lqiq=@iRuh@lqiq=h@ S/o/W/o/D/o ------------------------------------.............................................
.................................................................................................................
............................................................ Pin No./fiu dksM --------------------------------------------

8.

Hkqxrku dh fof/k@ Mode of Remittance

d esjs [kpZ ij euhvkMZj }kjk@ (a) By Postal
Money Oder at my cost.
[k eq>s lwfpr djrs gq, esjs cpr [kkrk la-vuqlfw pr
cSad@Mkd?kj esa js[kfdar psd@ bysDVkWfud ek/;e
ls vknkrk [kkrk lh/ks Hkstk tk,@ (b) By account
payees cheque/ electronic mode sent
Directly for credit to my S.B. A/C
(Scheduled Bank /P.O.) Under intimation to
me .

okWafNr fdlh ,d rjhds ij dksVd esa fVd yxk,a

Put a Tick in Box against the one opted

en la- 7 esa fn, x, irs ij@ To the address given against item No.7

cpr cSad [kkrk la-@ S.B Account no ---------------------------------------------------------------------CkSad dk uke@ Name of the Bank ---------------------------------------------------------------------------kk[kk@ Branch

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

vkbZ-,Q-,l- dksM @ IFS Code -------------------------------------------------------------------------------------------kk[kk dk iwjk irk@ Full Address of the Branch ..............................

.........................................................................................................
vfxze fVdV yxh jlhn uhps nh xbZ gS(Advance Stamped Receipt furnished below)
izekf.kr fd;k tkrk gS fd esjh iw.kZ tkudkjh ds vuqlkj mijksDr fooj.k lgh gS@ Certified that the particulars are true to the best of my knowledge .
LFkkiuk esa izosk dh frfFk@ Date of Joining the Establishment(dd/mm/yyyy)
tUe frfFk@Date of Birth (dd/mm/yyyy)
pkyw fok okZ dk vaknku@ Contribution for the current Financial Year okZ 2012&13 ls ykxw ugha (Not applicable from year 2012-13)
vaknku
Contribution
etnwjh
deZpkjh
Wages
EMPLOYEE
d-Hki-iSfuFP
EPF

O;o/kku dh vof/k ;fn dksbZ gks rks

Period of Break if any
fu;ksDrk
dqy
EMPLOYERS
TOTAL
d-Hk-fui-iSd-Hk-fui-iSEPF
FP
EPF
FP

ekpZ March
vizSy April
ebZ May
twu June
tqykbZ July
vxLr August

# lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fukku

Signature or Left / Right hand thumb impression of the member

eghuk
Month
eghuk
Month

eghuk
Month

eghuk
Month

etnwjh
Wag
es

vaknku
Contribution
deZpkjh
EMPLOYEE
d-Hki-iSfuFP
EPF

O;o/kku dh vof/k ;fn dksbZ gks rks

Period of Break if any
fu;ksDrk
dqy
EMPLOYERS
TOTAL
d-Hki-iSd-Hki-iSfufuFP
FP
EPF
EPF

flrEcj September
vDVwcj October
uoEcj November
fnLkEcj December
tuojh January
Qjojh February

# fu;ksDrk ds gLrk{kj /Employers Signature

d`-i-m-@P.T.O

www.epfindia.gov.in

;fn nkok izi= fu;ksDrk }kjk lR;kfir fd;k x;k gS rks ;g lwpuk fu;ksDrk }kjk nh tk,
(Information to be furnished by the Employer if the Claim Form is attested by the Employer)
izekf.kr fd;k tkrk gS fd mijksDr vaknku fu;fer ekfld tek /ku jkfk esa kkfey gSA Certified that the above contributions have been included in
the regular monthly remittances.
izkFkhZ us esjs lkeus gLrk{kj fd,@vWx
a wBk yxk;k gS@The Applicant has signed/thumb impressed before me.

fu;ksDrk ds gLrk{kj@ Signature of Employer

frfFk /Date ...............................

lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fukku

Signature or Left / Right hand thumb impression of the member

fu;ksDrk dk inuke vkSj eksgj

Designation & Seal of Employer
vuqyXud@ Encl.
ukSdjh esa u gksus dh ?kksk.kk@ Declaration of non-employment
fVIi.kh % d-Hk-fu- ;kstuk 1952 ds iSjk 69 ds mi&iSjk 2 ds [k.M [k vkSj mi&iSjk 1 ds [k.M p ds vUrxZr fuiVku ds fy, vkosnu djus ds ekeyksa esa nkok ukSdjh
NksM+us dh rkjh[k ls nks eghus ds ckn izLrqr djuk pkfg, ckrsZ lnL; yxkrkj csjkstxkj jgk gks vFkok ,slh LFkkiuk esa dk;Zjr gks ftl ij vf/kfu;e ykxw ugha gSA
Note : In the case of submition 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 un-employed in an establishment to which the Act applies.
lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fukku
Signature or left / Right hand thumb impression of the member
vfxze fVdV yxh jlhn dsoy mijksDr 8[k ds ekeys esa IkzLrqr dh tk,a
ADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above)
{ks=h; Hkfo; fuf/k vk;qDr@izHkkjh mi&ys[kk dk;kZYk; ------------------------------------------------------------------------------------------------------------------------------------------------ ls vius Hkfo; fuf/k [kkrs ds fuiVku ij
:---------------------------------------------------------------------------------------------- dh jkfk vius cpr cSad [kkrs esa izkIr dhA
Received a sum of Rs. ............................................................. (Rupees ............................................................................. only) from
Regional Provident Fund Commissioner/Officer-in-Charge of Sub Regional Office ................................................................. by deposit in my
Saving Bank account towards the settlement of my Provident fund Account.
frfFk /Date

{ks=h; Hkfo; fuf/k vk;qDr@izHkkjh mi{ks=h; dk;kZy;

}kjk Hkjus ds fy, NksM+k tk;s
The space should be left blank which shall
be filled in by Regional Provident Fund
Commissioner, Office-incharge of SubRegional Office.

1-00 :i;s dh jlhnh

fVdV yxkb;s
Affix 1.00 Rupee
Revenue Stamp
lnL; ds gLrk{kj ;k ck,a@nk,a gkFk ds vaxwBs dk fukku
Signature or Left/Right hand thumb impression of the member

vk;qDr dk;kZy; ds iz;ksx ds fy,@ (For the use of Commissioners Office)

[kkrs dk fuiVku fd;k x;kA QkEkZ la- 21&,@2 rFkk izR;gj.k jftLVj@3 i- iS- fu- izi= 9 lakksf/kr esa izfoV dh
A/c. settled in Part/Full Entered in F-21-A/2 and withdrawal Register/ Form 3 (F.P.F.) Form 9(Revised)
fyfid@ Clerk
iz/kku fyfid@ Head Clerk
:i;s ds v/khu@ Under Rs. ........................................................................................................................................... ................................................
Hkqxrku en laP.I- No.

euhvkMZj@psd
[kkrk laM.O./Cheque
Account No.
:i;s ds Hkqxrku ds fy, ikl fd;k@ Passed for payment for Rs.
kCnksa esa @(In words) ............................................................................................................................. ......................................................................
ys[kk vf/kdkjh
euhvkMZj dehku ;fn dksbZ gks@ M.O. Commission (if any)
Accounts Officer
kq) jkfk euhvkMZj }kjk nh tkuh gS@ Net Amount to be paid by
fnukad
M.O.
Dated
jksdM+ vuqHkkx ds iz;ksx ds fy,@ (FOR USE IN CASH SECTION)
psd lafnukad
jksdM+ cgh
Paid by cheque No. .................................................................................... Date ........................................................................... Vide cash book
ds [kkrk la[;k&1 en uke la[;k ------------------------------------------------------------------------------------------------ }kjk fd;k x;kA
and Account No. 1 Debit item No.
________________eq-fy-@ H.C.
l-vk-@{ks-vk@ A.C./R.C.______________________
www.epfindia.gov.in
vfH;qfDr;kWa@ REMARKS