Submitted online at UAN e-seva portal on 2020-06-27 14:02:02 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 - 9919677889
1. I want to apply for Pension Fund Withdrawal
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100590202893
3. Name of the member Kamini Pandey
4. Date of Joining 17-Mar-2017
5. Date of Leaving Service/ NksM+us dk fnukad 16-Nov-2019
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 DNCPK9840Q

8. Payee Address HARVANSPUR NR RTO

OFFICE,AZAMGARH,AZAMGARH,UTTAR
PRADESH-276001

* 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: Ram Nagina Pandey Date Of Birth: 24-Feb-1991
Bank Account Number 237601505750 Bank IFSC Code ICIC0002376
Bank Details ICICI BANK LIMITED,VIBHAVKHAND
Aadhaar 25XXXXXXXX11
Member ID UPLKO00518270000012960
* —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 - 100590202893 Tracking ID - 10059020289304001