wn () Employees’ Provident Fund Scheme, 1952 Form-19 (Refer to instructon) 1_-Name ofthe members in Block Leters. __EmrLovee NAME 2. Fathers Name or (husband's Name in the case of married woman) FATHERS NAaMe 3. Name & Address of the Factory/Establishment TEN DoWN THE AapeEss in which the member was employed. on Youg PAySith ate Oe A? [w)evme [yyyy Dato of leaving service LAST ploeerner Day 6. Reason forleaving service RESIGNATION [PERSONAL 7. Full Postal Address (in Block Address) ‘Shri/Smt/Kum. Yook — Post ~ SIOMVIOIDIO. panes Pn 8. Mode of remittance Puta tick (9) in the box against the one opted (@) By Postal Money Order at my cost. a) To the address given against item No. 7 Pur Ne NomeER (b) By account payee cheque sent (7) $8. Account No, casos “ESS Eatogae Underintimaton me. Ful adress ofthe branch ADELE” AS Fou ON ME Ciedve Sook ‘(avance Stamped Receipt furnished) Certified that the particulars are true to the best of my knowledge. Date of joining of Establishment... DATE... .OF TORN ING bates DAE, _oF Baty cig att ala Ye iis a scion Month | Wages 7 Month | wages epr_|rp|epe | ep |epr | rp cpr_jep|ere lee lever {ep(information to be furnished by the Employer i the Claim Form is Attested by the Employer) Certified that the above contributions have been included in the regular monthly remittances. ‘The Applicant has signed/Thumb impressed before me of Sg ess OO oot oir at aH roan Sane oi Detiaten Sea Be Declaration of non-employment Note In the case of submission 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 ciaim should be ‘submitted after two months ftom the date of leaving service provided the member continues to remain unemployed in an establishment to which the Act apples. pc 0ew 2 sue Yoot bate Signature of Let Right nand 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 Regional Provident Fund Commissioner / Officerin-Charge of Sub-Accounts Office by depos in my Savings Bank account towards the settlement of my Provident Fund Account ‘The space should be left blank which shall be filed in by Regional Provident Fund Commissioner/Otficer in-Charge of SA. Signature orLeft/ Right hand thumb impression of the member (For the use of Commissioner's Office) AIC Settied in partFull Entered in F, 21-A/24/219 & withdrawal register. Clerk ‘Section Supervisor es MO Cheque — passed for payment for Rs. M.O. Commission (if any) AOCIAPFC— Net Amount to be paid by M0 Date. (For use in Gash Section) Paid by inclusion in Cheque No. date. vide Cash Book (Bank) Account No.3 Debit term No He AC IRC Feavigtlée