Submitted online at UAN e-seva portal on 2020-01-21 18:03:43 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 - 9873119160
1. I want to apply for Pension Fund Withdrawal
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100342456070
3. Name of the member SAURABH KATIYAR
4. Date of Joining 05-Oct-2017
5. Date of Leaving Service/ NksM+us dk fnukad 21-Jun-2019
6. Reason of Leaving Service/ lsok NksM+us dk dkj.k CESSATION (SHORT SERVICE)
7. Permanent Account number / LFkk;h [kkrk la[;k BXIPK2540M

8. Payee Address 2207/3A Nandanpura, khati baba

road,Jhansi,JHANSI,UTTAR PRADESH-
284003

* 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: Rajeev Katiyar Date Of Birth: 08-Nov-1987
Bank Account Number 520101236608335 Bank IFSC Code CORP0002079
Bank Details CORPORATION BANK,NOIDA SHIV DAYAL PUBLIC SCHOOL EC
Aadhaar 67XXXXXXXX82
Member ID DLCPM00179540000010754
* —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 .
UAN - 100342456070 Tracking ID - 10034245607004001