wen opfindia.govin RereT Moti Number aaiard after ffir tre EMPLOYEES’ PROVIDENT FUNDS ORGANISATION, sige Tar or (areTe eis) COMPOSITE CLAIM FORM (NON-AADHAR) Ira 10 (rit Fate Perna (er seer Tn / 34 fbr FAR wT aftr eETIECH)] FORM NO.~ 19 (PF FINAL SETTLEME INSION WITHORAWAL BENEFTTS)'! (PF PART WITHORAWAL) 1 [eerie geen Rarer DRA. ec eite e( —_)) der eergcr rs ( Taye wraiiee rence) ST arER one er ere Claim app tor: Final PF Setterent (8) Pancon Winsraval Benes) )PF PART WITHORAWAL ( —) (arse eT Ree Tek whichever re eppscale) 2 | weer sre (rez we [Nae fhe member CAPTAL LETTERS) 3 | ee aed rat Woe (NAD Unboral Account Nomber(UAN)| * (ayer te (ag TTR ET Y/ PF Account Novincase UAN not avalatley | * _ 2 | enw (Pa RrtyAachar Number (or seeding: © | wo Reva Fate? Name: = - @: sa aft rare Musas Name © | see te of i 7 | weve ete # FS Date fang tho estbishment OAT RTA GR mt a Swe RTE TAA) Date of eaving sre: nt requirs applying for PF Part Watrawa) 9 [wer war toe a arate nee Taare (oot ase a et He, TR) Pemanent Account NoPAN): (Oni in case of servic ess than 5 years) (Peace eels wo copies of Fo No. 156/SH, I appcabe) 18) Ais eeter wren Reason of leaving Seve: Sb h(n) ere er () Saee we ger FETE TOT eee rer eA TOT Service teminaled en acount ofa) heath of member (0) Cntacton Discontinaton of emoloyer’s busines or) ther Cause bayond the conta of he member <_scterte/ Personal Reason 10 | eave rere wr ee GM RC Ye Ree Purpose of PF Pat Withdraml{Tick V wichave ppeabe) 15) (est amount Gn gp 1a) afore gh red bet ane ar A TRA aR raha cf fr we rca tee Pe rrr ao For purpose ‘of SteMovsfiat or Constacton tough “agony” or Repayment of Housing Loan or LIC, Indicate cheque ote drawn "In fovour of an payoo's adress. Te aie eer rate Papen Pat et ee ea tage met oftehn) scene ome ae (tT entucaantvcastey Housing LoenPuchase of staourait or for CCoretuciowAdton, ateraton. in exsing houseRepayrent ot Housing loan (ara 83688516880) eT (Para 654) Gaia) Loon or cosure ot factory iB eer eC) nas of mamberfiemiy (Para 68) wee eatin re a) Mariage of sllson atte foter stor (Para 68K) v [estate ane fan cer eo) Pst watreuaton euoaton of cron (Para 68k) va gt reer 60m) Natura calamity (Para 681) | ere a A (ER) Cutin locity i eatabehmant (Para 8M) vat | enter Free i wf (7 65%) ‘Advance or Physlaly handicapped (Para 68N) i [aa Hea gate Ose One year beer etremont Para 62NN) | een ter tar aro (teeserere) overeat Varsha Pension en ojane (Pare GENAN) 1 | ene eB wr Fee nk Account els for payment gre er be Arte rege qe ee AAA He (Crease atach a copy of carcaed chequeatstes copy frst page of Pass Book) “ae erat Saving Bark Acoout No. “Beerrre me / Name & adress of the Bank axkice tte AFS Cote 2 | aera ul Pot soiree fara. wae endeared eer See tecon ATA arf cong freer Mane aA “The member hereby decres hat he as not been empoyed fx wo mons (YeSNO}) - Cried that the partials are tue tothe best of my knowledge. “ago s ret ir (10) Ea Me ee eH A a a WaT TT we Fe Tee Incase te amounts ved fr any purpose aber than stated in clu (10) above, am aba to run the nie amount wih pena incest reer eee Members Sonate ‘rier ea! Employer's Signature ‘eter en 04 Oesloration® Seal of Eroovervi) vi) vil) ix) eae ara wo (ree & Far) wer eae aTyeAT INSTRUCTION SHEET FOR FILLING THE COMPOSITE CLAIM FORM (NON-AADHAR) safer er ser ct rr eet (weer Parr aT ew et AT 8) Purpose of advance & documents required. The purpose may be one ofthe following aero Aa ce Pe Rey aaa we rare Boe ea eT st ATA Fe BRE cet are ear nets TT a ge aR oT ae aT A AT Housing Loar/Purchase of stahousefia or for construction/Addtion alteration in existing house/Repayment of Housing loan: No document is required. New Declaration Fom/Uitlization Certificate required earier has been discontinued. weeaaftare Fharéh: i) rece er Fares we ii) Pea are Taree Re eer aT crab Fre ahr sre gt er are eg aT TET ness of memiberamiy:) Certificate of doctor and i) Certfcate by employer that ESIC facility isnot avaiable to the member may be submitted by the member eet A ge Rea: et fe TEE Mariage of sotson/daughterforotherisister: No document/Mariage Card is required ee are eet A oaTE: HE cea a A A Post Matriculation education of children: No document i required ot er aca are Re TGA ae Sh AE eT a ET AI Lockout or ciosure of factry/Cut in supply of electricity: No document is required sph aver: até cera wr ft th Natural calamity: No document is required. arte er & Ree rer wewee wee Ry Aas TIT RIT Bh Purchasing equipment by physically handicapped: Medical certificate is required. erg Be ek: wt PARE: or AA 903% Prue A ar a AE ee ET ‘One year bofore rtrement: 90% of otal PF balance canbe withdrawn. No documents required. af ter or ahora te: Aor AAA Her Aer oT 90% ora AT Fre Hake Par aT Tw BI BE eater ar ae Investment in Varistha Pension Bima Yojana: 90% of total PF balance can be transferred to LIC. No document is required. 2 en eT TET TOT (4) TA AY aT ET No Revenue stamp (Re. 1/-) is required to be affixed by the member. 3, ara (Bree) rer aT BAR Bar § ack (60 ae) Hv Ay aren Let) set wre TET aE GT Te 50,000 & ri enh srt Aree 10% A xe H rer UCT AAR aree or eG CAT Bl Ae TT TE fare oh TH 34,608% A xe Ate eT TET Income Tax (TDS) is deducted ifthe service is less than 5 years (60 months). No Income Tax (TDS) is deducted in case the total balance is less than Rs, 60,0001-, However, TDS is deducted @10% ifthe member submits PAN in such cases, In case PAN isnot submitted, then TDS @34 608% is deducted. care ae areca Fteeht eer get Bear A ra AT ah, sta: eA wt FAR re wy Cw ATT fro or gaa fear rar ‘The total service in the present establishment as well as previous establishment is counted and, therefor, it is advisable to merge all PF accounts 4. eer Rrra ara eae a ar a eat & a aT ae Ee Pension Withdrawal benefits can be avaled only if the service is less than 10 years.