Contact No: _____________ Personal Email id: ________________

PF WITHDRAWAL APPLICATION

Form No 19
For Office Use Only Inward No.

EMPLOYEES PROVIDENT FUNDS SCHEME 1952 FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEMES,1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES(PARA-72(5)). (Note: Read the instruction carefully before filing this form) (All correction/Alteration should be attested by the Employer) Employee Number 1. Name of the Member (In block Letters) Emp No _2072455 2. Parent Name (Husbands name in case of the married women) 3. Name and Address of the Factory/ Establishment in which the member was last Employed 4. 5. Code No & Account No. Date of the Leaving Service

Mukesh Bhatia Ajay Bhatia

Name of the Employee Fathers /Husbands Name

Will appix the company seal PF Number

KN/25075/40108

14 Oct 2009
6. Reason of the Leaving Service

Last Working day

Resigned

Leave blank

7. Full Postal Address (In Block Letters) Please furnish correct address/information

No 480 2nd Cross, Prestige Apartments West of the chord Road, Rajajinagar Bangalore-560036 Present Postal Address

8. Mode of the Remittance Put a ticket against the any one (A) By postal money order at my cost if the amount Payable exceeds Rs.500/(if the amount payable is Less than Rs.500/ M.O commission will be come by the PF Office. Payment Exceeds more then Rs.2000 above will not made through M.O. B By Account payee cheque send direct for credit for the SB A/c any Scheduled Bank/Post Office/ Co-operative Bank) under intimation to me (Advance stamped receipt furnished below) Please furnish the S.B. A/c.No duly optioned in any nationalized bank/Scheduled Bank/ Co-operative bank with the Full postal address of the bank

M.O

CHEQUE

to the address given in Item No 7 S.B A/c no 0014690000321 E.C.S No Name of the bank H D F C Bank Branch Alwarpet Branch

Bank Account Number Leave Blank Name of the Bank Address of the bank with the Pin address

Full Address of the Bank HDFC bank Brigade Mansion,Jeevan Bheeema Nagar, Alwarpet Chennai-600012 CERTIFED THAT THE PATICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date of Birth/Age Date of Joining Establishment Date of Leaving Service

12 .01.1983 10.03.2003 14.10.2009

Date of Birth Date of Joining Date of Leaving

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me. Signature of the central Spoc with the Authorization seal Signature of the Employee

Date: Signature of the Employer/ Signature/left hand thumb impression of the Authorized Official with rubber stamp Member ___________________________________________________________________________________________________________ Declaration of the Non Employment Note : in the case of submission of application for settlement under clause (E) of sib paragraph (1) and in clause(2)of paragraph 69 of the EPF scheme 1952 , he claim should be submitted after two months from the date of Signature of leaving service provided the member to remain un-Employed in an Est. to which the Act applies. the Employee Date : Signature/left 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_________________________________________ ________________________from the Regional Provident Fund Commissioner/Officer in-charge of Sub Regional Office _____________________by deposit in my savings bank account towards the settlement of my Provident Fund Account. The space should be left blank which shall be filled in by Employer Provident Fund Office. Affix Re.1/Revenue Stamp

Signature/left hand thumb impression of the member on the Revenue Stamp

Signature of the Employee (No need to paste the revenue stamp)

FOR THE USE OF COMMISSIONERS OFFICE Account settled in Part/Full entered in F.21/A/24/2/9 and withdrawal register Clerk Section Supervisor __________________________________________________________________________________________________________ Under Rs.___________________________________________________________________________________________Only) P.I No__________________________M.O/Cheque_______________________A/c N KN/BN__________________________ Section ________________________________ Passed for Payment for Rs._________________________________(In Words) Rupess__________________________________________________________________________________________Only) M .O.Commission if any _______________________________________________Date____________________________ Net Amount to be paid by M.O_____________________________________________________________________ EE Interest up to Amount Authorized Date : A.A.O/A.P.F.C FOR USE IN CASH SECTION Paid in inclusion Cheque No ____________________________________________dated_____________________Vide cash Book (Bank) Account No 3 Debit Item No. C.W S.S AAO A.A.O/A.P.F.C Remarks Acknowledgment received on __________________________________________________Verified on____________________ ER TOTAL

Contact No: _____________ Personal Email id: ________________

EPS WITHDRAWAL APPLICATION

Form No 10-C(E.P.S) Employees Pension Scheme-1995

Inward No:

FORM TO USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
(Read the instructions before filing this form)
1 (A) Name of the Member (In Block Letters) (B)Name of the claimant (s) Date of Birth

Mukesh Bhatia

Name of the Employee

12
2. Date of Birth 3 (A) Fathers Name (B) Husbands Name (If Applicable) 4. Name and Address of the Factory/Establishment in which the member was last Employee. 5.Code No & Account No

01

1983

Fathers/Husbands Name Will appix the company seal

Ajay Bhatia

______________________________________________________ __________________________________________________________ RO/SRO CODE EST. Code No A/ c no KN/25075/40108 PF Number

6.Reasons for Leaving Service & Date of Leaving

Resigned 14
nd

Date of Leaving

10

2009
Present Postal Address Put a right mark inside the box

7.Full Postal Address (In Block Letters) Sri/Smt/Kum S/o.D/o.H/o.W/o

No 480 2 Cross, Prestige Apartments West of chord Road,Rajaji nagar Bangalore-560028

8 Are you willing to accept Scheme Certificate in lieu Withdrawal Benefits?

(A) Yes

(B) No

9.Particulars on Family (Spouse, Children or Nominee) Name Date of Birth Relation with the nominee

Leave blank Name of the the minor

(A) Family Member(s) (B) Nominee Leave Blank

10 Incase of Death of the member after the age of 58 years without filing the form. (A) Date of the Death of the Member

(B) Name of the Claimant(s) and relation ship with the member. ____________________________________________________________ 11. Mode of the remittance (PUT A TICKET IN THE BOX AGAINST THE ON OPTION) (A) By postal Money Order at my cost to the Address given in the Column 7 (B) Account payee cheques sent direct for to credit to my S.B A/c (Scheduled Bank to me under intimation to me Put a right mark inside the box

S.B A/c no ECS Code No

0014690000321
____________________

Bank Account Number Leave blank Name of the bank

Name of the Bank ( In Block Letters) H D F C Bank Full postal address of the branch (In Block letters) HDFC bank Brigade Mansion,Jeevan Bheeema Nagar, Alwarpet Chennai-600012

Full Address of the bank

Leave Blank 12 Are you availing under EPS-1995 If so Indicate PPO No ____________________by Whom issued__________________________ ____________________________________________________________________________________________________________ ____ CERTIFED THAT PARTICULARS ARE TRUE TO THE BEST OF THE MY KNOWLEDGE Signature of the Employee Date: Signature/left hand thumb impression of the member/Claimant(s) ADVANCED STAMPED RECEIPT (To be furnished only in case of 11 (b) above) Received the sum of Rs.____________________________________(Rupees________________________________only) From the Regional Provident Fund Commissioner/Officer in-charge of Sub Regional Office, by depositing in my savings bank A/c towards the settlement of my Provident Fund Account. The space should be left blank which shall be filled by this office Affix Re.1/Revenue Stamp Signature of the Employee (No need to paste the revenue stamp)

Signature/left hand thumb impression of the member on the revenue stamp

Leave page blank

Certified that the particulars of the member given are correct and the member has signed/thumb impression before me. The details of wages and period of non-contributory services of the member are furnished under Form- 3A/7(EPS) enclosed for the period for which was not sent the Employees Provident Fund Office Date of Joining Wages (Basic+D.A) As on 15/11/95 (if Applicable) Wages on the date of Exit Period of Non-Contributory Services Y M D

Date

Signature of the Employer/ Authorized official with Rubber stamp (FOR THE USE IN COMMISSIONERS OFFICE)

Under (Rs.____________________________P I No_________________________________ M.O.Cheque ____________________ Passed for the payment for Rs._________(Rupees)___________________________________________only) M.O commissioner (If any) Rs.____________________net amount to be paid by M.O __________________towards withdrawal benefit. D.A S.S A.A.O

Paid by inclusion in Cheque No___________________________________________date _________________vide Cheque Book Account No 10 Debit Item No______________________________________ D.A For issues of S.S :IDS is enclosed D.A S.S APFC (A/CS) S.S AC (CASH)

(FOR USE IN PENISION SECTION) Scheme Certificate bearing the control no scheme certificate control register D.A S.S Issued on and entered in the APFC (Pension)