www.epfindia.gov.

in

Mobile Number

, 1952
EMPLOYEES PROVIDENT FUNDS SCHEME.1952
-19 / Form-19
1. / Name of the member

2. ( / a) / Fathers Name ( / a):

( / b):
( / b) / Husbands Name
3. / Date of Birth

4 / / Name and Address of the Factory /

Establishment
5 ( / a): . / P.F. Account No. ( / a):
.....................................................................................
( / b): (...) /Universal Account Number(UAN) ( / b):
6 / Date of Joining the Establishment

7 / Date of leaving Service

8 / Reason of leaving Service

....................................................................................................
- () () /
( ) , ....................................................................................................
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

9 * . ( )
*Permanent Account No.(PAN) ....................................................................................................

* 15 / 15 ( / )
....................................................................................................
* Whether submitting Form No. 15 G/15 H , if applicable (Yes/No)
15 / 15 , ( )
Please enclose two copies of Form No. 15G/15H, if applicable

* 5 /Only in case of service less than 5 years

10 - / Full Postal address
....................................................................................................

....................................................................................................

....................................................................................................
Pin ..............................

11 / Mode of payment: /Saving Bank Account No.

( )
Put a Tick against the one opted ( ) ......

()
(a) By Postal Money Order at my cost OR Name of Bank
() /
(b) By Account Payee Cheque/ Electronic Mode of payment
Address of the Branch .
.......................................................................
( / Please attach a copy of cancelled
. .
Cheque/Attested copy of first page of Pass Book )
IFS Code

( / ) / The member hereby declares that he has not been employed for two months (Yes/No.)

/ Certified that the particulars are true to the best of my knowledge.

/ / The Applicant has signed/thumb impressed before me.

/ Members Signature / Employers Signature

/ Or / Members thumb impression / Designation & Seal of Employer

/ Date ...............................
/ 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.
.... /

/

Affix Re 1/- Revenue
stamp & signature/thumb
impression
.................................................................................................................
/ ( 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.

/ Passed for payment for ` :. ... /TDS Rate %:

... / TDS Amount ` :.

... / Amount after TDS ` :.

( ) / M.O. Commission( if any)

/ Net Amount to be paid by M.O. Accounts Officer

/ Date :

( ) / ( FOR USE IN CASH SECTION)

Paid by cheque NoDate Vide cash book
-10 ....................................................................................
And Account No.10 Debit item No.

--------------------------------.. / SS -------------------------------------------------------------------------------------- ./ A.PFC.----------------------------------------

/ REMARKS

____________________________________________________________________________________________________________________________________________

Claim ID/ .. (for official use/ )