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Form 19
Form 19
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Number
GTCIT~/Clam
I.D.
~~-f.'tfil"~.1952
EMPLOYEES' PROVINDENT FUND SCHEME. 1952
U"q"'jf-19/ Form -19
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From to be used by major member of the Employees' Provident Fund Scheme, 1952 for claiming the
Provident Fund dues [Para72] (5)]
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Name of the member(in block letters).
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Father's! husband's Name in the case of married
women
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lflIT I!If /Name and Address of
the Factory !Establishment in which the member
was last employed.
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5.
qlt ~lDate
6.
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7.
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2.
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3.
ofleaving Service
/Reason
of leaving Service
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ShrilSmt.lKumari
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S/ofW/o/D/o
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/ Mode of Remittance
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EMPLOYEE
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EPF
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March
April
~May
"l.'l June
~July
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Signature
Form 19 (www.epfindia.gov.in)
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EPF
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Contribution
TOTAL
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~October
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November
~December
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January
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Page lof2
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!Employ's Signature
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(Information to be furnished by the Employer if the Claim Form is Attested by the Employer)
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1/ Certified that the above contributions have been included in
the regular monthly remittances.
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Signature of Employer
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Received a sum of ~
Commission/Officer-in-Charge
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(For the use of Commissioner's Office)
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Nc. Settled in Part/Full Entered in F-21-N2 and with drawal Register! Form 3 (F.P.F.) Form 9(Revised)
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Accounts Officer
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Paid by cheque No
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Date.
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<1.31T./el.31TI A.C.IR.C.
~/REMARKS
Form 19 (www.epfindia.gov.in)
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