Submitted online at UAN e-seva portal on 2021-03-26 21:05:50 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 - 9730349007
1. I want to apply for PF Final Settlement
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 101411941503
3. Name of the member MADHURI MAYUR DALAVE
4. Date of Joining 01-Jan-2019
5. Date of Leaving Service/ NksM+us dk fnukad 30-Jun-2020
6. Reason of Leaving Service/ lsok NksM+us dk dkj.k CESSATION (SHORT SERVICE) - Any other
reason

7. Permanent Account number / LFkk;h [kkrk la[;k ENVPD8582C

8. Payee Address SANGLI

SANGLI,SANGLI,SANGLI,MAHARASHTRA-
416416

* 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: MAYUR Date Of Birth: 05-Aug-1992
Bank Account Number 60327101808 Bank IFSC Code MAHB0001955
Bank Details BANK OF MAHARASHTRA,CIVIL HOSPITAL SANGLI
Aadhaar 64XXXXXXXX05
Member ID PUKOL18243010000010012
* —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 - 101411941503 Tracking ID - 10141194150301001