yy {ree ee = ISSUED FREE OF CHARGE. rE, p Retin 39 1958 gen 15 eden elm gbdends edGeg OM 1958 qb ggoirig.cr 15 yb Qo. aru CrwanuGP mPangs otrid ‘THE EMPLOYEE'S PROVIDENT FUND ACT, No. 15 OF 1958 “ ec" eae 09.9 jus A gtb “Ga” [FORM “K” Oe ome / 1 ged ura PARTI ned 23 bm Bouts ded ect flow ager nogced Sedna Bast omed 26 Dauisis der BB Ko BEES. BeierBamd sci pel 23 24d Uaipamon, Carhssiir Comins) cammineres, bute egerterOyisay. Bcorpany> ocLp et 26 yb Mfodasnm, Qriuyd Csnfsan. ‘CLAIM made under Section 26 ofthe Act, by a member ofthe fend for benefits payable under Section 23 ofthe Act. A (extrtince goer 829 odds mad ® edomakioan beck 08 ettreckinm Witt 268 pees oGQe mac exitatid cnc @O ete er) (Qatsnfamsimeg, 2 gia ae fune Game ump Camdsuignns cgmd Gynfd symamnesis sgHGGe Coad (Tis claim should be sent tothe Commissioner of Labour through the employer under whom the member was last employed.) I oxnana. seh ep ed } Full Name of member's mother 5. mpirfexosaljcotobeesDox SEqsa! /AoPeasoed aPpies me (Come BBe8) : (epider) ebansuncrannicr) sans sar bbe 0) Full Name of member's spouse if married) 6. cottanssaleoteteass ddmbacele B69 oP agenda cnt sda Cs guineas mmcanend Opis, Ganetaupie. master Qudarsinar goanenssed sommes} ‘Any natural distinguishing marks of member 7. cored geo (edbnsaitacosd gens com emeBeosd! | coBrlasded guns eunzst 8, gael Eas 0 epeccin) Apu haw Gatanect Cemasaus sues Batspeosnd a niirfc Bautagmoyd aps "i" vbprbBertor guia aicmteumid Gaomdaeyd ) Membership Numbers (tate employers number and memb's number; also stach membershipcand -“B” Fo) (@) Oem acinacico dee maBiadd mee |e oer (20 sah Bevomtaint ppuaster dp 2 piuiionn Be. = os (@). Membership Number under lastemployer (@) 20 Goh scooeaktatat eden! Bet deed sooo go 00 09 gram OG gay Ys, Cane ent Obes (a) Yiu danmesdoet pguiesfor degeer a punyfinis ations afsbghg, aake Pap. wna. oe oer (©) Membership Number under previous employers if ny. and the date, Month or year of leaving such employer 8. crtfeced | entsbeded das on coe } epuuberfer ews Jpoys Based ‘Age and date of tinh of member 9, qdenm ecioaalieacs SOS adds ad Gos } sh Vise darontais baerhes hbk Sere Se Bo Bacon which employment cated mde thea employer 10, abe madB80 exigd (smee 25 88 Onellis am 2 De BED oom Boston) } mp Pence anzema CaBangs ax pick 230 ead? yb ubss Bp @Sdeuyid ind2s) Cause of cessation of employment (vide Section 23 the Act and Note at page 2) 11, gO ectnacennae! 8 ca Bes aD Lanmantsind bavarfie Qumagid wpa [Name and address of the last employer (eas nea EPF ON?DHSS NEA® cod Seiad /CsAw ser wien ICs weit aug csscit / PARTICULARS OF NATIONAL IDENTITY CARD eee i (688 Beindded qfiotiead exids ecieien DAs} omBian me cofiea Gut = Oph gamer conse ee swikouccaro nagPoed Sonat 20 sp Nae apring o anu eae mda 8 agus Geese a ‘In addition to this a copy for the National Identity Card certified by the wegted gee employerisanexed Sahn amines Cam: Bes {Seniy CaN. wiggtest Sega oe tou: Bd? ors wonders 60d SS Date of Issue } = } Ded SED SSOROD ACO) OTST ass sors UTA GUGUT GRE Gib/ FOR HOLDERS OF BANK ACCOUNTS 8649 O50: - 985 8808 | 4.08 Ege 790d 3 sowie coma - OauBu/ Leen nities Guu? “Type of Account- Savings -Current Account Name of Bank See qme x9 sO soni Bs. ‘arias Deer ‘Account No. Bank Branch gon ages! ad RE Bq SED B(5 8800 ASOD OIE cdsios! (2yea covet BGP gas Geom BYRD does Boal 2 2dq O08, Bae ge) ue Ortig Torey eib.sner vow fang sor, Oui aapluie aniRAaersse (eaciR.saiie yponpaba sndnenaubed ac coor Bath) Please order the cheque enabling credit tobe made o my Bank Account of the aforesaid Bank. a. : ee wo iesoionh Maomcupriuies axcarBed Signature of the Member 8 cmb [ouesiact # 5,G0UGAee0 | Name Cerificate T, cdeina | Bixe anlias e908! ipo /elarrad eneepigyier und "Name in Binh Certfcae/ Mariage Ce 2, Bem mggBon 900 29: Oahu emumer sycmdeeuy, Suu ‘Name in National emity Card 3. “PrmB om qgo 22: “U" upgopberus Quod ‘Name in “B* Card (Membership Card) 4, 8 Spee oe. ¢ 4. 8508S cxwet 9 :- viene wp fuer me de 9. sewad [Name in EPF Account at Central Bank of Sri Lanks Ge Gus gon one n® Badecnio mfcltatet oe eae; BO ea 08 ecomseccand en Bude @iidLcucr adand Cuupeaso Queer du oBbet wm a pSAObs Ore Ganpc seis naduncu Thereby cotta rane above mentioned ae referred fo one andthe same person. Signature of Employer cotati | eatmbad OoeO 88 oeet 8 aad : ppuiiertey maiaugatre remcariersiae! ae os ‘Thum Marks of Member ae cabssauved / esdodensee! galaodet San o,S8 ‘sderibeod! could qdeloosad gus ep anfe GOUADNO maLiGugedyamLurerassA (rrargieog uefa Goud Signature of witness to signature and Thumb Marks of Member cpeldaged 98. god oD 87 | ees genpcasarfior Bou). used, paws aot ‘Name, Designation and adaress of witnessTI de cemdes (seiDrecsiesencn BOsi mB ges ne, gen) 11 gid ursis Camevrsaiog sguasfieaned Dy tutus. Cassie ws) PART II (To be filled in by the Employer) + BBB oan (ann oye pean | Oe gcd] eam Oo | AAG OD. 5108. metho (eset 6) tctoaad eaxstn of 80 ebde! audio adh, Oy | qo wdda cbomtm gdeced SEximeas | waa ay lees Spe | gees fom adob cue 10 Om adkend gave =e wad Bx Bap 26) aaa, eos vad odd | mselda. Sun! | ge! Bed ebabecssei® § cao Oo Gy=Q00 ado GB gd. glam Sansd am Bee 20. vr ead O26 ESD gyaest EO CH (oa) gelfle “ 2” (8) Gxt) B80 99 Op | ge Ogotad | etds and a6 Fo eas! oom” eBge® ommat oun Bed quoted Soc edie qteentia ecge sbgabe § eas Sw SpqOd 9BGdl o> of Bede 62 (2a Bed geaee Som et BOY cndin =cB, (03) gem & endian / enoaiond gSiea Gg0 quae! od. Seed [gees BUPDRAG EPee! a. Fo g—EHO Lo eae gnc be/anumbpe 7 “gs uenn und ggetennparQuiaiSu On bes /orumnpsbarvpancnanned Bef Lnsmanned/eitoared -- «ie are/ amis Bthans) eser qs Ape / ence psan bes Gen anifud Beunmspider a pcitercvaid. Gang © fimss Ban famadar 10 eb ubhS) apiuc. anvenesipara Ga Opn Peiedass, Bowron fcrpns/sBargserprd. Guns, aga Oprmeact uRparaid Wbbu arid snLuciuc German. Beir g aan.4 wns £00) Garaact, 20. RD ns ng bB bee 2 p01 Garensash UDiPu Bur oB9i 4s ACU RAdUL Geter. Gam F (go GATADTG oepcuuc. Ber Ap "g” Daendaticcanny acter agai Qgnaase dadu/aercnn iu Bes eit) APSSLOUCD. texifut ArvarURPdamrads wb WOOAs Bree HgyLiyeder UonpOsnasaesocUEsiuc Gees 00 ets epculer) ae yaretmasded Gara faoks GUABLGEOID/ gg ex uGjeby ewer DeGerennd soot lo ereby certify that. Membership Numer " ) wasemployedas inthe above estate establishment and that he shes a member ofthe Employees Provident fund, He! She is retring/ leaving employment for the reason stated in paragraph 10 of his/her claim, Hs! Her contributions have been ‘emited in fll to the Cental Bank and the last month's contributions were included the retum of the contribution forthe month of a) (02) Lcenty that, since the submission of telat C (3) return, the contributions as shown in Annexe “below have been recovered up fo the de of leaving/ retirement and have been incladed inthe remittances made by me tothe Central Bank on Account ofthe Employers Provident Fun (03) ‘The said member signed the claim and affixed his/her dhomb marks in my presence. emcee 0) et focus | Signae Erploye'sNmber Go| a6 [Dee Sooo maser gomen Joydel 8 oe gene 862/14" Gevewriny/ Annex ‘D? (go 8 (3) Satan babel 99 § cm Sy300 ado 9:8 cu Bed) (enun(arebe B09 ngoader 3a Ob/bu areas pce. 35 Oprencet ‘Contiton remit to Cenual Bank afer subission of last C (3) Rete) erschiniond BaRO gee sdomaed 433 oe oe) ‘Employer's Registration Number Employment Number) = cuneas Saree ‘oat bee cnn Me | oeee aoe 1 Barbed sosrass | | Toul Earnings ed Borage secures “om Coataons = ‘cca FS] Se . SS Signe and Designaon of Engle 60-028 469 aPates me pet mo Oromd Ode (3) Baan glen! mm edPreeeaes OA Lg RASA sep UrENG LD A87 Gaertn Oa Bat RGus 4 Bs Boe Bone and Nit—Twis Annexe shouldbe filed aly by employers who arc required io" bal eal eur in orm C3)ecitn ecsinamd cose 01, “eet” gona emped Bede ecdacoes bet § c= 6m ArROO af Bad “Bom B 3” fad Ootmde Squat Oo not eyoede ay, Souler mdsin (me B90 earn ends med Fd anda Ocoris) BEaB SeOa00x! esas OB 88c1 om® pyimow qqnd mado aD BA Safin 26 d ADD GAs gem OB was "20" 29 qmd8a! goat ad ayfe eaieond Benin Gach msin® BO» aBpfiesem "A" oat "83" nd Batis 3m asp SBalwrend Bo) 20 OB 8", "8", "2D" oy ack og2d afer 08 (q) “at” gomiBl aged ii Om smded Gam Bed oN qOsom Gros BORO qed OS afd oSateo ms Agate. (ep) 808 goam" 83" end entimn oDueat og § oo Om BROS ae Ed Som GuID® “BD” RABE oBabia ndaio 20.528 mas quo Bid 8 3” Ons Oot ce G3 800 8a Seooeto geBadOsio crecst 08 680 Sigal dp cfm cose Glam oxoet qBige! 20 BABE ¢ 08 em gba! me IS goed Bag® 2st mead motions Bet gfe gone eB eq mds aang RO. pK qaePen BBO easoto (Reet | 2) mB BotinG cm pfoRN0 OBE ROO NOY Be HAE 2ntaia qaxgBon ens ROD oBeetin GOOD Boa GS) ars Bea! 3.5m x {Sem BK Cfins erencoont ewe Bers 955985 panies 01. "Os" (K)utrbOD npr mips Gursibiobsou ering Bhi yencr3u"F"(C).sag)"43"(C3) e808 £949 GBHUUCGeter GuUgi 94DGAEEperasN ebUMBE FINI AaR/E. (OABARLL BD OUUI WpsBanpbsiemeD (pasuorerene) DargKnG en gndeyADgi5er IANA! G7 groMrA GpLuarare fret enekpien7 86s) Oat 08 “S"(A). "I" B), "28" (H) Ce et ofscedas sp UGUC Oehenawasn eeruipeers Osiihs) Ganehenayd. "ee" (H) sib edeeon bist Devnbcy> 03, (3 e.paj Ogres Grgrdbu ceo Murs “Oa” (K) Ubb0dsd ii qub unas Bed ears wicik uC BoeOscisamer Bheiaaasd, (ap) aaah aan. °F3" (C3) 801780 Get ana spew masbacisGoererCarsrigenee BrrdAsal.. Aemnemrinisrd sends sifeinb5® © Bégre QmmrsacncOeren Saipbss iy 6 DARED ABET ubsrRiaes LngIh GanAsayD. Gi) pbeungy.raesionass & Gpryn> sesamiae at... ereotoacoer Fateh IE Daer £46) BL Asp Aenssennyt> SER Geiger. store # siser gy borofiny& Qaingih ene isaner RsineSAe iad siBLLONS Rshed LoTeNLL. HNiRB! 1) Ggnife:smgyaraseg Sui Der rey a9 NBS Bart. (i eee can oon Ring bd Gur gy apoineminhed er dais pg) yenasis (3.5 $y 4.8) Qos ora ind ised Oaveia Db Instructions for the Emplovers, OL. Check whether Employee's name given in “K" form and your “Cor “C3” Return sent to the Central Bank tallies, (Spelling and inttials are important) if there is any discrepancy you should certify by aleter that the names refer to one and the same person. (02. Check whether “A”, “B" and “H” Cards have already been forward. I'not, complete them, check with “C* or “C3” Retum and annex to application. (3, (a) ‘See that the last month of contributio~ is correctly entered in part Il of “K™ form, (©) Ifyouhave sent contribution 1oCe:_ Bankafter submission of your last ‘C3 return, complete the “D” annex. Ensure that all past C3" returns have been finished. Instructions for the Applicant @ Please attach the velevant documens 2s stated inthe instruction form. (We arsanged to Refund bencfits at all our District Labour Offices. You should submit your claim application personally reaching tothe nearest District or Sub Labour Office. ii) Recent Photograph (Bust ofthe member size 3.Sem x 4.5em is necessary atthe time of handing over the application. Ped, moses Bsns emosunend. ‘Commissioner of Labour.