Submitted online at Member e-seva portal on 2025-09-03 18:15:03 (IP www.epfindia.gov.
in
Address:10.70.13.115)
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 Member Portal and UAN has been activated.)
Mobile Number / eksckby uacj - 9406821434
Tracking ID : 10067154427701001
1. I want to apply for PF Final Settlement
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100671544277
3. Name of the member DEEPAK PATHAK
4. Date of Joining 01-Apr-2022
5. Date of Leaving Service/ NksM+us dk fnukad 30-Apr-2025
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 BANPP0758C
8. Payee Address 56 YOGIPURA
HARSIDDHI,UJJAIN,UJJAIN,MADHYA
PRADESH-456006
* 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 Member Portal and found all data including Form
No.11 (New) , bank account details and Aadhar Number to be correct
Father/Husband/Spouse Name: RAMESH CHANDRA PATHAK Date Of Birth: 17-Jul-1987
Bank Account Number 0887053000000166 Bank IFSC Code SIBL0000887
Bank Details SOUTH INDIAN BANK,UJJAIN
Aadhaar 66XXXXXXXX30
Member ID MPUJJ23945880000010022
* —i;k ;w-,-,u-iksVZy ij n'kkZ, x, cSad [kkrs esa Hkqxrku djsaA
* Please make payment in the bank account mentioned in the Member portal .
* The bank kyc has been online verified by bank and has been digitally signed by the employer for this case among
other validations and therefore mandatory uploading of the image of cheque leaf/attested bank passbook is not
required.
