wera optnda govin Motte Nunbar EMPLOYEES’ PROVIDENT FUNDS ORGANISATION COMPOSITE CLAIM FORM (AADHAR) ‘APmacanL CASES HERE EAPOEES' COMPLET DETAILS IN FORM: 14 (NEW), MORAR NUMBER AMO BANK ACCOUNT DETAILS ARE AVAEALABLE OW WAN ‘PORTAL AND Ut AS EEN NEVA. ‘UrORM NO. =19(P ETNA, SETTLEMENT / 06 (PENSION WITHDRAWAL BEMETTS/ 33 (PE PART WITHDRAWALS} TT] Claim applied for: i) Final PF Setterent ( —) i) Pension Wiherawal Bones (y Ti) PF PART WITHDRAWAL( (ick whichever is/are appicabe) 2 | Name of the member: (IN CAPITAL LETTERS) 3 Universal Account Number (VAN) | Radha Wamber 5 | Date fring the extabishment 7 2) Purpose of PF PART Withdrawal: Tick ¥ whichever applicable) [S| aaa or ac al —[ ert os 1 osig Loar Purchase of ste/hansgGt 2 ue, ‘or for Construction/Addition, alteration in 9 for puose tse or Cosrcton rough "oer or | | | eng hosel Repoert Hosa ean fepornert of Howing Laon or Le Mice caus Be Soh ar te /eonea) “in fevour of and payee's addres, Lockout or closure of factory (Pra 68H) ‘a _[tiness of memberfamiy (Pare 68) IN [Marriage of slf/son/caugheerfrathe7 sister (Para 684), [Post Matriculation education of caren (Para 68K) vi_| Natural clarity (Para 681) Wi | Gutin elecvity in establishment ‘Para Sh) Vil [Purchasing equipment — by — physcaly handicapped (Para 68h) ik One year before retirement (Para SENN) %_ [lavestment in Varsha Pension BmaYojana (Para GBNN) Date oF eaving Service: (not required Fappiving for PF Part Wirawaly 8 a)Peranent Account No,{PAN): (Ory Io case of serie Tes han 5 year) (Pease enclose two copies of Form No. 15G/15H, if applicable) 1) Reason of leaving Service: ~ Service terminated on account of (2) i health of member (b) Contraction /D'scontinuation of employers business or (c) Other Cause boyord the contol o the member + Personal Reasons 3 | Fal Pos adres - 4 Pn, ~ Gard thatthe partiaiars are true othe best of my knowedge, I cert that Ihave gone trough the data seeded in UAN Portal and [Bind at dat incudiog Form No.-Lt (New), bank acount deta and Aadhar number, tobe correct. Pease mate the peyment he creat mentioned in the UAN Portal canceled cheque (containing members name, bank acount rune aed IFS Coe) attached herewith ~ jhe the amounts used for any purpose other than tates in column (6) above, 1am ible to ret the entire arount with penal intrest. Member's Sgnature