Submitted online at UAN e-seva portal on 2019-05-17 09:43:10.0 www.epfindia.gov.

in

deZpkjh Hkfo"; fuf/k ;kstuk] 1952

EMPLOYEES' PROVIDENT FUND SCHEME,1952
EMPLOYEES' Pension Scheme,1995
UAN Based Combined Claim Form 19/10C WB/31 for Advances/PF Final Settlement/Pension Fund Withdrawal
(mu ekeyksa esa ykxw tgka QkeZ 11(u;k)esa deZpkjh dk iwjk fooj.k] vk/kkj la[;k vkSj cSad [kkrk la[;k ;w-,-,u- iksVZy vkSj ij
miyC/k gS rFkk ;w-,-,u- esa lfØ; gSA)
(Applicable in cases where employee's complete details in Form 11(New),Aadhaar Number and Bank
Accounts details are available on UAN Portal and UAN has been activated.)
Mobile Number / eksckby uacj - 9655354553
1. I want to apply for PF Final Settlement
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 101193452914
3. Name of the member LAKSHMI PONNUSAMY
4. Date of Joining 02-Apr-2018
5. Date of Leaving Service/ NksM+us dk fnukad 31-Jan-2019
6. Reason of Leaving Service/ lsok NksM+us dk dkj.k CESSATION (SHORT SERVICE)
7. Permanent Account number / LFkk;h [kkrk la[;k FABPP5502E

8. Payee Address 456

AMMAPATTI,KARISALPATTI,SINGAMPUNA
RI,SIVAGANGA,TAMIL NADU-630309

* eSa çekf.kr djrk gw¡ fd eSaus ;w , ,u iksVZy ij lhM MkVk dks Hkyh Hkk¡fr ns[k fy;k gS rFkk QkeZ u- 11( u;k ) cSad [kkrk fooj.k vkSj vk/kkj
la[;k lfgr lHkh MkVk lgh ik;k x;k gSA
* I certify that I have gone through the data seeded in UAN Portal and found all data including Form No.11
(New) , bank account details and Aadhar Number to be correct
Father/Husband/Spouse Name: RAJENDRAN Date Of Birth: 30-Jan-1993
Bank Account Number 009501000121471 Bank IFSC Code IOBA0000095
Bank Details INDIAN OVERSEAS BANK,TIRUPPUR
Aadhaar 45XXXXXXXX03
Member ID CBCBE00344370000012865
* —i;k ;w-,-,u-iksVZy ij n'kkZ, x, cSad [kkrs esa Hkqxrku djsaA
* Please make payment in the bank account mentioned in the UAN portal .