EPFO

Annexure K

Application No and Date :

Name of Subscriber :
Account Number from which :
Transfer is made

Name & Address of Factory :

Establishment in which previously
Employed

New Account Number :

Name & Address of Factory :

Establishment which
employed at present

Contribution : (a) Employees Share (b) Employers

share

Opening balance as on 1st April (a) (b) Rs.

Contribution during the year (a) Rs. (b) Rs
Interest credited in the current year (a) Rs. (b) Rs
Total credit to the Account (a) Rs. (b) Rs

Withdrawal during the year, if any (a) 0.0 (b) 0.0

Amount transferred (a) Rs. (b)

Total (a+b) Rs.
Date of commencement of scheme :
Total period of continuous service :
of date of commencement
of scheme
Date of leaving service :
Date of birth of Subscriber :
FPF Contribution details : S.No Amount of single conts

Breaks in Reasonable Service : Nil

Cheque No and Amount : Cheque No Dated

Drawn on ____________

Bank