Submitted online at UAN e-seva portal on 2022-02-24 11:02:14 (IP www.epfindia.gov.

in
Address:49.37.159.190)

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 - 7871928349
1. I want to apply for PF Advance
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100557288354
3. Name of the member MEDISETTI VINEELA

4. Date of Joining 09-Apr-2019

5. Permanent Account number / LFkk;h [kkrk la[;k CVZPM1570R

6.a Purpose of Advance Illness

6.b Amount of Advance (In Rs) 50000

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 41-1/5-109 gouthami nagar 1st line krishna

lanka,vijayawada,KRISHNA,ANDHRA
PRADESH-520013

* 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: SAIBABU M M Date Of Birth: 14-Apr-1994
Bank Account Number 027601518442 Bank IFSC Code ICIC0000276
Bank Details ICICI BANK LIMITED,CHENNAI - NELSON MANICKAM ROAD
Aadhaar 22XXXXXXXX32
Member ID PYBOM00463700000870782
* —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 - 100557288354 Tracking ID - 10055728835406001