Professional Documents
Culture Documents
in
Mobile Number
, 1952
-19 / Form-19
1.
2.
( / a) / Fathers Name
3.
( / b) / Husbands Name
/ Date of Birth
( / a):
( / b):
( / a):
( / b):
.....................................................................................
6
() () /
( ) ,
Service terminated on account of (a) ill health of member (b)
Contraction /Discontinuation of employers business or (c) Other
Cause beyond the control of the member
....................................................................................................
....................................................................................................
....................................................................................................
....................................................................................................
/ Personal Reasons
* . ( )
....................................................................................................
( / )
(Yes/No)
....................................................................................................
15 / 15 , ( )
Please enclose two copies of Form No. 15G/15H, if applicable
11
/ Mode of payment:
( )
Put a Tick against the one opted
......
( )
()
(a)
()
(b)
Name of Bank
OR
Address of the Branch .
( / )
.......................................................................
. .
IFS Code
/ The member hereby declares that he has not been employed for two months (Yes/No.)
/ Members Signature
/ Employers Signature
/ Enclosures:
( )
ADVANCE STAMPED RECEIPT (To be furnished only in case of payments through cheque)
`................................................................
Received a sum of `...from Regional Provident Fund Commissioner by deposit in my Saving Bank account towards the
settlement of my Provident Fund Account .
Kindly do NOT paste revenue stamp in case of payments through NEFT / Electronic mode.
.... /
/
.................................................................................................................
/ ( For the use of Commissioners Office)
21 /2 / 3 ... 9 ( )
Account settled in Part/Full Entered in F-21-A/2 and Withdrawal Register / Form 3 (F.P.F.) Form9 (Revised)
... / SSA
. . / SS
_________________________________________________________________________________________________________________________________________
.
P.I. No.
M.O./ Cheque
Account No.
` :.
Accounts Officer
/ Date :
-10 ....................................................................................
And Account No.10 Debit item No.
____________________________________________________________________________________________________________________________________________