ure far er megmne. grey vite eprart ty Prefer fron aren wer Cuomt ) ds rer Set Following information should be furnished afona with claim form to expedite payment through ‘.E.E.T (National Electronic Fund Transfer) | wee ata Priyanka Resour Member's! Claimant's Name m= Alene, 2. | wferer Pir rer der Region Code, Jt. code ; EE Account Number LDIALHOI1S320002 455649 Member's Date of Birth 2 sfufrare 4.) des aa aan are Wem Claimant's S.B. Account Numi IF \e | Gaerne ome —_]119]0|tfo| 9] 3/4]>]e S. | en Sar Ger aT ——— Axis Gente ©) das whe ar eT war E-1u6 Saker, Ned clas Complete Bank Branch Address = Noolt 7. | Sem aie er STSTLA Ste TET CIE sa G IFS Code of Bank Branch (11 digits) Ult]t] elolo | o] ofl jo a alaant ar Hanger Aart ante arg et aT daleB rls ak Q Mobile no ot clatmant if any Rawas 199.6 PiyackoCS Forel: Gorm 9] #3 te Uh. UH. HIS STAT IS ) Sera Ht E- Mail Address. If any ‘areeer sre a (eave) ae Breer Sra Sag wren Been A erdhes Sew wre ger Ae we Pes wt ere Tel See Ses has Detiey Fore Sas wren eT, BEET AG, eas TTT Ve Us Ses TT a (SHE Nore ;- Member should enclose attested copy of first page of bank pass book or a copy of cancelled cheque or bank statement bearing account no., member name, bank name & full branch address and IFS code of bavk branch. Wary aden & gears Member's) Claimant's Signature'sMax Financial Services Limited Employees’ Provident Fund Tri FORM 19 : PROVIDENT FUND SETTLEMENT APPLICATION Theprovident Fund Trostees Dearsies youto pay he fllamount standing tomy ceatln the fund afer mating sich deductons a maybe authored under he PowgencFund Trust nero come Te porta area Below Ieeicme Tax ce 1967 . [kane otthemember \usttyan Fa Yaudat V Monae og Raat + [Fathers Name [3 [Rusband's Name irtoyee code {Sa [5 |lecation/Unit Fear acount Number TUANT CT aaT ees eae + [PE Recount Number F [Aodhaar Number (12 digits) LDIAL 021123 200° LASS EIA [stented cont hn 61862 0331-2617 9 [iccenone veered ue copy ofthe PAN Cad) ‘1 CAA PR 62 3% 7 pate af Binh (OOMMATYIYI relepare 77 [Bate af Foring TOOMATT aT o3- [ast 72 [bate of Leaving (ODMMITYO) eal oe 204 1 [Reasons forleaving service 7 = = 17 [Sender (WaleFermaie) = o SI Te ie Hab Taasrvine Peyean gr 17 [Restience Phone Nurnber with STO Code Sf Sepa stash tional 3 Te rem indlan, essa ones copyofPssprt NDIA [Complete Res. Address with PIN Code Binto-$-3 26 Aw Usha phate- 1 angler Toad pethi— Woot 3 [rvcsfncon sev ceredsro copy ofresidentaladdress root Duprote eve meyeryerh [coon shout othe non Name TA oloogyresa6) Ti IFS Code of the Bank Branch (11 digits) zt] UTaBosooszy Fr [Name of Meribers Bank Beis Basie pao pape Safes of Members Bank wih PNCOOE : Tar Perr TS38 6 Bante- | Ground fies jay VS 380 [an nice one Onl anced Chea pe ON de ae Sac Ave of a Broce C7 Lyoped Najer-Y Ha Patrtoyet bth 5 7a FEROS Seca tae Copy of Farm 16 from the Lee jung to ane of tena, tn com the] [1 [9923-2024 [a] Da ee ees having membership forlesthan S years : ployee is having membership forlessthon Seer | [72032 022 |4 Gablinment to which the Employees ere St nat less than 2 months imme rovident Funds and Miscellaneous tely preceding the date of my | declare that Ihave not been employed in any factory or other Provisions Act, 1952 (PF Act, 52) applies for 2 continuous ps pplication for withdrawal of my provident fund money. snd fully Indemnified from and against all losses, My amount having being proved to be based on a false cost or damages, which you may ‘declaration at any time In thereby agree and undertake to keep you harmless at suffer or incur due to my withdrawal of provident fun furure. ‘Settcertfied true copy of document(s) in suppert of my application is/are furnished/enclosed. {certify that the particulars glven above are true to the best of my knowledge. wo. See rat oe oom ‘slgnature of Member 101,08) 22 of company with Samay ated