PROFORMA

AFFIDAVIT-CUM-INDEMNITY BOND

I___________________________________(Block Letter)
S/o.D/o.W/o__________________________________residing at ___________________
__________________________________Permanent Address of____________________
____________________Taluk_______________________District__________________
State________________
Solemnly affirm and state on oath as under:1. I state that I was an employee M/s_________________________________
(Name and Full Address of Establishment) from _________________________
To______________________________________________ and holding
P.F.Account No.KN/_________/__________ with the Regional Provident Fund
Commissioner, Regional Office._____________________________________
Karnataka and DECLARE that I am the Actual Account holder.
2. I am herewith submitting PF claim Forms________________________________
And I hereby undertake an indemnity to Central Board of Trustees Employees
Provident Fund Organisation, Ministry of Labour, Govt., of India that this claim if
later found false. I shall be responsible for any loss incurred out of this
transaction.
3. I declare that I have NOT withdrawn my PF Accumulation/Withdrawal benefit of
F.P.F 1971/ Employees Pension Scheme 1995 till date in respect of my above
account.
This Affidavit-cum-Indemnity Bond has been executed by me and state that facts
mentioned therein are true and correct to the best of my knowledge and belief.

DEPONENT
(NAME)
Solemnly affirmed and signed before me
On this day of_______________
ADVOCATE
(With Seal)
BEFORE ME
(1 CLASS JUDICIAL MAGISTRATE)/PUBLIC NOTARY(WITH SEAL)
ST