FORM NO.

19 RGPJ-578(DTP)/09-5000 FROMS

EMPLOYEES PROVIDENT FUND ORGANIZATION –JAMMU

To,

The additional provident fund commissioner

Jammu

I hereby requesting you to pay me the full amount standing to my credit in the fund after making such
deduction as may be authorized under section 74 and 76 the schedule

1. Name ………………………………RAKESH KUMAR……………………………

2. Father’s Name …………………………KARTAR NATH………………………..
3. Name and address of the factory /Establishment: -
4. Account Number ……………………………………….…………………………………………….
5. Ground on which the request for withdrawal is made …………………………………………………………….
6. Date of leaving Jammu & Kashmir State…………………………………………………………………
7. The payment may be made by …………………….… ……………………………………

Bank A/c No. ………….. Bank ………………… ……………………………….

Branch ……………………………………………………..IFSC code ……………………………………………………………

8. Particulars of last subscription i.e. ……………………………………………………………………………………………

Month and year

I certify that particulars given above are true to the best of my knowledge

Signature or left Thumb

Impression of the member

Certify that above declaration has been made before me by ………………………………...employed in

………………………………………………………………………………………………

Signature of the employer

Manager with Seal