Submitted online at UAN e-seva portal on 2022-01-19 21:59:48 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 - 8692975958
1. I want to apply for PF Advance
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100951049542
3. Name of the member AZHARKHAN AFZALKHAN DALWAI

4. Date of Joining 10-Feb-2020

5. Permanent Account number / LFkk;h [kkrk la[;k BEIPD2741C

6.a Purpose of Advance Illness

6.b Amount of Advance (In Rs) 25000

7 In case of Advance for purpose of Site/House/Flat Not Applicable

8 Bankers details for Electronic Payment (Only for the Advance if payable to Not Applicable
third party)

9. Payee Address 501,Patel Palace, Sector 18, Plot 3,

Kamothe , Navi Mumbai,Navi
Mumbai,RAIGARH,MAHARASHTRA-410209

* 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: AFZALKHAN DALWAI Date Of Birth: 08-Apr-1993
Bank Account Number 123801520896 Bank IFSC Code ICIC0001486
Bank Details ICICI BANK LIMITED,NAVI MUMBAI KAMOTE, MAHARASHTRA
Aadhaar 46XXXXXXXX82
Member ID THVSH16492910000010203
* —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 - 100951049542 Tracking ID - 10095104954206007