(1 6 7 00

6 4\ PL, E F .kri
19
.4,0 it/ Mobile Number (latr ivixtot
q>iqfvitr 4 crzkrt i f4/ For Office use only

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9) '91 tIiitszTF4R1- ztIV91, 1952
EMPLOYEES' PROVINDENT FUND SCHEME. 1952
wt 19/ Form - 19
TIF tb- 114 Bfas7it - 4T4T t1.14 W4-41t1 F4Rf ti+10- 1 Vir671. tiGv4.1 girl ITU vitt,
From to be used by major member of the Employees' Provident Fund Scheme, 1952 for claiming the
Provident Fund dues [Para72] (5)]
3 r4- slwA 3 3 116(4 WTIu t 4-a/(Read the instructions before filing up this form)
tt<4 wr 'ITI (FITZ 3 1E- T0 A)
Name of the member (in block letters) VI k AS ICUMAg.
2. 144114i T4111 (fdqlfgcr 411d- ra4 i 4- ri4- 1,4 4)
Father's/ b.usbaird's Name in the case of
married women
64- I . S U N / 1- -
k
1 )
M A R . .
3 rtitlleiPT9T .111 a tEdi Wilii *lq'241 3 4i " , f
4F ft- 4ff 1- 4k4 Trzrr tA/Name and Address of
the Factory /Establishment in which the
member was last employed.
OR l EA/ - 711 I_ ilEA/CY
i Li A , kA k0 L 8 A 0-1 I V E I N ) bEtill - I I O 0 o5
/
4.
olor 4./ Account No. 3
D t__ C- P /`/// / 1. 27t3 ,
5. tWe BYZA Wit/Date of leaving Service
3 0/ 6 1.26 13
6.
k
',5.XA J P/k 7/6 A./ - -
ATh- fl '6+- 3 - 4 air 4,1xur/ Reason of leaving
Service
7. EM a.14 6H tT TM
Full postal address (in block letters) 413 /4triit/T4r3 )/ Shri/Smt./Kumari VI kA S
k
U milk
1- P/A- 41 /3E- 41 / S/o/W/o/D/o .. iL l - - c 0 Ni L kuNA.iK .
- - A T/VVA k PuR I
t ,
,, ,,-
A law bE L1 1 1
Pin Nolf4A q)ls //0
,..,_
C/ I.) 44])..
8. ra- t4 it ftf4/ Mode of Remittance
(T) 43 tai 43 4413 4-43 gm/ (a) By Postal
Money Oder at my cost.
(g )
- TO TL I -d - 4rtt g 43 trtrf elicitizt.(3 1-glitff
gad- Will crwu- '4- tR - 3 1z- - 4 f e c t, 0 , 1N
Put a 'Tick' in Box against the one opted
( ) 44 3 4. 74 ftc 471;0 43 / To the address given against item No.7
( Ne/r ovt d" .:1<t) 'calm 3 4./ S.B Account no 0 7 3 Olro 6 Ci 6 a I
44, wt / Name of the ArA
strut/ Brch
V
Bank .STAT.E
\NAKP
8R A fic ,0
I lv h 1 4
Bran
Oki
3 rt...cr-fr. ct,) / IFS Code 6.8.)N OD 2306 0
A - I Twit wr 17L3 r 44T/ Full Address of the Branch ,
40 / l'OtO A 01.):KI - cr)/ Oct5,Ing, 'TT6717
tr 3 Tr-4- r-dr oicir ttt) - 4r 'lilt/ (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 .
TM I A - KPOZI , N . . 1 ) FLOI - 1 1 6 0 -6 ,
(84tirr twz ci'ft e rfl< l't tt lit t)(Advance Stamped Receipt furnished below)
Arfrilff 1 , zlr ,yilor t f'iOr tkr4 .41tol4i i 3 r-j3 A3 \i4x141- r fdckur ,9a t/ Certified that the particulars are true to the best of my knowledge .
,3
...T rEFT # 44st ffif4/ Date ofJoinin the Establishment
/2
O
. 2. oci.
r tf4/Date of Birth 05. 06 /0'70 (dd/mm/yyyy)
=lig I'd a4 wr sign((/ Contribution for the current Financial Year (44 2012- 13 tr oil At) (Not applicable from year 2012- 13 )
(dd/mtn/yyyy)
fferd - t atsg m 0.10- 11.1 aR arer oft 4t t ff1
Month Contribution Period of Break if any
,ig rI T 3i3K M arairi 48 are( oft *1 w1
Month Contribution Period of Break if any
-
i
P.
.Mtjf1
Wages
4i47r41
EMPLOYEE
Pa al c 141
EMPLOYERS
V
TOTAL
,
cy'''
'MO
Wag
es
9, 41
EMPLOYEE
q aril
EMPLOYERS
T..,
TOTAL
TI T.
EPF
qtt.
FP
T.,T.1.
EPF
R.4.
FP
WAA.
EPF
0.
FP
TR
Pt.
EPF
4.4.
FP
- . ,T.
1'4.
EPF
4.4.
FP
11'.
Pt.
EPF
q.4.
FP
wr4 March Riot September
34,:tApril ara ae October
'T May 1 ,1 1 1i November
June Rtp- ,K December
ri4 July w9a81 January
arrro August w-fall February
k71\fO rtin11191VtAl
# FiTTIL973 itrat 4- k/T.g Trzt of 3 I- TOfAstF
Signature or Left / Right hand thumb impression of the member
www.epfindia.gov.in
#f)ttichtt 6i- cirffl3 /Employer's Signature
P.T.O
1:11o,y ) ALe to
aR
Affix 1.00 Rupee
Revenue Stamp
z,virrt
01/1
qiai wt itictor & I tr qf Trzrrt at TF9r
(Information to be furnished by the Employer if the Claim Form is attested by the Employer)
11 iifalcT eal wlci1 t 3 171-4- (9 fauflcr OTT wqr ,<1 r 4 vrrI4F t 1 Certified that the above contributions have been included in
the regular monthly remittances.
well 443 ,(1144 Titrat3 f+- 7/SPI-d( (1 4 112 41 t/ The Applicant has signed/thumb impressed before me.
61/404
zi <tor 6i- c 1I ks1 .1/ Signature of Employer
ifti /01)- 0 1a
f*1 /Date
fr zl) c h- 11 TR94 41YR.
Designation & Seal of Employer
,/
arm/ Encl.
twft 4 9 t- 4- l 1.41guir/ Declaration of non- employment
Rtmuir : z4-A- 9( 1952 I T 69 37 NT (2 ) tg .4 ((TT) 3P1t 37- 171 (1) z 314ff 3T1 t49 . mt1 Arr- ral A 'M.- 4T 91 - - it
ffiftEt T zl 4)4 vig-d q t rrftnlct *14t- 4 c .1 , 11c 1H d tlwmH 3 -6- r 3 m-4( titt 7e1rc(9- r 4 wrtiff tR 3 #?ii449 c.+141
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.
ffRE /Date / I 1 6 ) 1 3
tiqt4 6t.1141't 3P- T7f q- r/ Ter. 41.0 fZ11- 1
Signature or left / Right hand thumb impression of the member
3 11t4 fewe ci41T411- 4 (ms- - 4- -& \3 tNlctvr s(u) 91 ,1c 4 at vilq)
ADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above)
4-4t4 41'011 3 nzive1fsp11t 3 4- - c)r arcr4 Af4Ezt 1'41r Pavel - r aR
) r 3 144 wuct ur0-
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.
tiqvi Trra- T NWT A- N/Tq TeT 3#0
Signature or Left / Right hand thumb impression of the member
tkltzr 4ftsEr MR( 3 trzpV74rt ztralttt q iokio
gkr 474 t f to.) 51
The space should be left blank which shall
be filled in by Regional Provident Fund
Commissioner, Office- incharge of Sub-
Regional Office.
tiqter Tirrat- 3 Trr TraT 3#0 r 14sTr9
Signature or Left/Right hand thumb impression of the member
arrEsr velicv( 101 , 1 fWg/ (For the use of Commissioner's Office)
f)Liefri f+- zi1 TRI T rb- i4 ti. 2 1 v2 - ffETT CruT <DtCq3 A. A. fk AT 9 (-074R1- d ) AftZ
A/c. settled in Part/Full Entered in F- 21- A/2 and withdrawal Register/ Form 3 (F.P.F.) Form 9(Revised)

l'A:4T/ Clerk

3 T>1r4 i'MA- T/ Head Clerk

t)L4 3 (44/ Under Rs.
Tr-d - M 4-4- T.

4113 tr-43 /A- T

P.I- No.

M.O./Cheque
t441 rffri um 140r/ Passed for payment for Rs
4)/(In words)
4t3 1Ttq a4lxri 0 1Z q> l4 t) / M.O. Commission (if any)
3 1- 10m- rft
s14 .flfir 4tatr43 5 kr t uir- Tr t/ Net Amount to be paid by

Accounts Officer
M.O.
Dated
tlinr
Account No.
(4c o l 3 r-141- 4 ;ROT * f'= - 7)/ (FOR USE IN CASH SECTION)
- <t) 3 4. ft- 4(w, ct, . #1
Paid by cheque No. Date Vide cash book
t51c 11 tit- Q.11- 1 44 1 - rf tit- Q11 g kr f+- zrr Trzrr I
and Account No. 1 Debit item No.
lifk./ H.C. Ra(r./4.3 (r/ A.C./R.C.
www.epfindia.gov.in

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