Form19
- 1. www.epfindia.gov.in 爐爛爐爐鉦爐 爐伍 Mobile Number 爐爐爐爐爐鉦ぐ爛 爐爐朽た爐劇爐 爐朽た爐朽た 爐爛爐爐逗ぞ , 1952 EMPLOYEES PROVIDENT FUNDS SCHEME.1952 爐爛爐萎お爐む爐 -19 / Form-19 1. 爐伍う爐伍爐 爐爐 爐逗ぞ爐 / Name of the member 2. (爐 / a) 爐朽お爐むぞ 爐爐 爐逗ぞ爐/ Fathers Name (爐 / b) 爐爐朽い 爐爐 爐逗ぞ爐 / Husbands Name (爐 / a): (爐 / b): 3. 爐爐爛爐 爐朽い爐朽た / Date of Birth 4 爐爛 爐爛爐爛爐萎/ 爐伍爐逗ぞ爐爐逗ぞ 爐爐 爐逗ぞ爐 爐 爐爐むぞ / Name and Address of the Factory / Establishment 5 (爐 / a): 爐爐朽た爐劇爐 爐朽た爐朽た 爐爐鉦い爐 爐伍. / P.F. Account No. (爐 / b): 爐爛爐朽た爐逗じ爐爐 爐爐鉦い爐 爐伍爐爛爐爐 (爐爛.爐.爐踱.) /Universal Account Number(UAN) (爐 / a): ..................................................................................... (爐 / b): 6 爐伍爐逗ぞ爐爐逗ぞ 爐爛爐 爐爛爐萎た爛爐 爐爛 爐朽い爐朽た / Date of Joining the Establishment 7 爐逗爐爐萎 爐爛爐÷た爛 爐爛 爐朽い爐朽た / Date of leaving Service 8 爐逗爐爐萎 爐爛爐÷た爛 爐爐 爐爐鉦ぐ爐 / Reason of leaving Service - 爐伍爐逗ぞ 爐伍ぎ爐鉦さ爐 爐爛 爐爐鉦ぐ爐 (爐) 爐伍う爐伍爐 爐爐 爐爐萎ぞ爐 爐伍爐逗ぞ爐伍爛爐 (爐) 爐伍爐爛爐爐 / 爐朽た爐爛爐爛爐むぞ 爐爐 爐朽爐爐鉦お爐鉦ぐ 爐爐爐 爐項爐逗 爐爐逗た爐 ( 爐 ) 爐爐爛爐 爐爐鉦ぐ爐 爐爛 爐伍う爐伍爐 爐爛 爐朽た爐爐爐む爐萎ぃ 爐伍 爐爐鉦す爐 爐項爐 , Service terminated on account of (a) ill health of member (b) Contraction /Discontinuation of employers business or (c) Other Cause beyond the control of the member - 爐朽爐爐朽い爐爐 爐爐鉦ぐ爐 / Personal Reasons .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... 9 *爐伍爐逗ぞ爐爛 爐爐鉦い爐 爐伍. ( 爐爛爐 ) *Permanent Account No.(PAN) *爐爛爐爛爐爐 爐爛爐萎お爐む爐 爐伍爐爛爐爐 15 爐爛 / 15 爐踱 爐爛爐萎じ爛爐む爐 爐爐 爐萎す爛 爐項爐 ( 爐項ぞ爐鉦 / 爐逗す爛爐 ) * Whether submitting Form No. 15 G/15 H , if applicable (Yes/No) 爐爛爐爐爐 爐爛爐萎お爐む爐 15 爐爛 / 15爐踱 爐爛 爐爛 爐爛爐萎さ爐むく爐鉦 爐伍爐迦爛爐 爐爐萎爐 , ( 爐爐爐 爐迦ぞ爐爛 爐項 ) Please enclose two copies of Form No. 15G/15H, if applicable * 爐爛爐逗げ 5 爐逗ぐ爛爐 爐伍 爐爐 爐爛 爐伍爐逗ぞ 爐爐逗さ爐 爐爛 爐爐鉦ぎ爐迦 爐爛爐/Only in case of service less than 5 years .................................................................................................... .................................................................................................... 10 爐爐む爐-爐朽爐爐逗す爐鉦ぐ 爐爐 爐爛爐萎ぞ 爐爐むぞ / Full Postal address .................................................................................................... .................................................................................................... .................................................................................................... Pin 爐朽お爐.............................. 11 爐爛爐爐むぞ爐 爐爛 爐朽た爐朽た / Mode of payment: 爐逗ぞ爐爐朽爐 爐爐爐伍 爐踱 爐爛爐劇爐爐 爐爛爐 爐爐逗 爐迦爐鉦踱 ( ) Put a Tick against the one opted ( ) (爐) 爐爛爐萎 爐爐爐 爐爐 爐爐朽た爐爐÷ぎ爐 爐爛爐朽ぞ爐萎ぞ 爐爐逗た爐 (a) By Postal Money Order at my cost OR (爐) 爐爐爐 爐爐鉦い爐 爐爛爐 爐萎爐爐鉦爐爐爐 爐爛爐/ 爐爐迦爐爛爐爛爐む爐萎ぞ爐朽た爐 爐爐鉦ぇ爛爐爐 爐伍 爐爛爐爐むぞ爐 (b) By Account Payee Cheque/ Electronic Mode of payment (爐爐爐逗 爐爛爐爐 爐爐鉦い爛 爐爛 爐萎う爛爐 爐爛爐 爐爛 爐踱 爐爛爐萎さ爐 爐伍爐迦爛爐 爐爐萎爐 / Please attach a copy of cancelled Cheque/Attested copy of first page of Pass Book ) 爐爐爐 爐爛爐爐 爐爐鉦い爐 爐伍/Saving Bank Account No. ...... 爐爛爐爐 爐爐 爐逗ぞ爐 Name of Bank 爐謹ぞ爐爐 爐爐 爐爐むぞ Address of the Branch . ....................................................................... 爐爐.爐踱 爐踱.爐爛爐 IFS Code 爐伍う爐伍爐 爐爛爐朽ぞ爐萎ぞ 爐爐 爐爛爐萎爐爐 爐爛 爐爐鉦い爛 爐項 爐爐 爐逗す 爐爛 爐爐鉦す 爐伍 爐爐項爐 爐爐鉦ぎ 爐逗す爛爐 爐爐 爐萎す爐 爐項 ( 爐項ぞ爐鉦 / 爐逗す爛爐 ) / The member hereby declares that he has not been employed for two months (Yes/No.) 爐爛爐萎ぎ爐鉦さ爐爐 爐爐爐爐 爐爐鉦い爐 爐項 爐爐 爐爛爐萎 爐爛爐爐 爐爐鉦た爐爐鉦ぐ爛 爐爛 爐爐逗爐伍ぞ爐 爐爐爐萎爐爛爐 爐朽た爐逗ぐ爐 爐伍す爛 爐項 / Certified that the particulars are true to the best of my knowledge. 爐爛爐萎ぞ爐逗 爐逗 爐爛爐萎 爐伍ぞ爐爐逗 爐項じ爛爐むぞ爐爛爐劇ぐ 爐爐爐 / 爐爐鉦爐爛爐爐 爐迦爐鉦く爐 爐項 / The Applicant has signed/thumb impressed before me. 爐伍う爐伍爐 爐爛 爐項じ爛爐むぞ爐爛爐劇ぐ / Members Signature 爐朽た爐爛爐爛爐むぞ 爐爛 爐項じ爛爐むぞ爐爛爐劇ぐ / Employers Signature 爐爐逗た爐/ Or 爐伍う爐伍爐 爐爐 爐爐鉦爐爛爐爐 爐朽た爐謹イ爐/ Members thumb impression 爐朽た爐爛爐爛爐むぞ 爐爐 爐爐爐逗ぞ爐 爐爐 爐爛爐項ぐ / Designation & Seal of Employer 爐朽い爐朽た / Date ............................... 爐爐逗爐迦爛爐爐 / Enclosures:
- 2. 爐爐朽た爐 爐爐逗爐 爐迦爛 爐萎じ爛爐 ( 爐爛爐逗げ 爐爛爐 爐爛爐朽ぞ爐萎ぞ 爐爛爐爐むぞ爐 爐項爐逗 爐爛 爐爐鉦ぎ爐迦 爐爛爐 爐爛爐萎じ爛爐む爐 爐爛 爐爐鉦) ADVANCE STAMPED RECEIPT (To be furnished only in case of payments through cheque) 爐爛爐劇爐む爐萎爐 爐爐朽た爐劇爐 爐朽た爐朽た 爐爐爛爐爛爐 爐伍 爐爐爐逗 爐爐朽た爐劇爐 爐朽た爐朽た 爐爐鉦い爛 爐爛 爐朽た爐爐逗ぞ爐 爐爐 `................................................................ 爐爛 爐萎ぞ爐朽ざ 爐爐爐逗 爐爐爐 爐爛爐爐 爐爐鉦い爛 爐爛爐 爐爛爐萎ぞ爐爛爐 爐爛 爛 Received a sum of `...from Regional Provident Fund Commissioner by deposit in my Saving Bank account towards the settlement of my Provident Fund Account . Kindly do NOT paste revenue stamp in case of payments through NEFT / Electronic mode. 爐爛爐爐爐 爐踱.爐.爐踱.爐逗. /爐爐迦爐爛爐爛爐萎ぞ爐朽た爐 爐爐鉦ぇ爛爐爐 爐伍 爐爛爐爐むぞ爐 爐項爐逗 爐爛 爐爐鉦ぎ爐迦 爐爛爐 爐萎じ爛爐爛 爐爐逗爐 爐 爐迦爐鉦踱爛 ................................................................................................................. 爐爐爛爐爛爐 爐爐鉦く爐鉦ぎ爐迦く 爐爛 爐爛爐萎く爛爐 爐爛 爐朽げ爐 / ( For the use of Commissioners Office) 爐爐鉦い爛 爐爐 爐朽た爐爐逗ぞ爐 爐爐爐爐 爐爐爐 爛 爐爐鉦ぎ爐 爐伍 21 爐 /2 爐むた爐 爐爛爐萎い爛爐爐鉦す爐萎ぃ 爐萎さ爐爐伍爐逗ぐ / 3 爐.爐爛.爐朽た. 爐爛爐萎お爐む爐 9 ( 爐伍爐謹爐朽た爐 ) 爐爛爐 爐爛爐萎さ爐逗さ爐劇爐 爐爛 Account settled in Part/Full Entered in F-21-A/2 and Withdrawal Register / Form 3 (F.P.F.) Form9 (Revised) 爐伍ぞ.爐伍.爐伍す爐. / SSA 爐爐逗. 爐爐爐. / SS _________________________________________________________________________________________________________________________________________ 爐爛爐爐むぞ爐 爐爐 爐伍. 爐爐逗爐爐÷ぎ爐 / 爐爛爐 爐爐鉦い爐 爐伍. P.I. No. M.O./ Cheque Account No. 爐爛 爐爛爐爐むぞ爐 爐爛 爐朽げ爐 爐爐鉦じ 爐爐爐爐 / Passed for payment for ` :. 爐逗.爐÷.爐踱. /TDS Rate %: 爐逗.爐÷.爐踱.爐萎ぞ爐朽ざ / TDS Amount ` :. 爐逗.爐÷.爐踱. 爐爛 爐爐謹爐爐鉦い爛 爐萎ぞ爐朽ざ/ Amount after TDS ` :. 爐爐朽た爐爐÷ぎ爐 爐爐爛爐謹た ( 爐爐爐 爐爛爐 爐項 ) / M.O. Commission( if any) 爐迦爐爐 爐爐朽た爐爐鉦ぐ爛 爐謹爐爛爐 爐萎ぞ爐朽ざ 爐爐逗爐爐÷ぎ爐 爐爛爐朽ぞ爐萎ぞ 爐爛 爐爐鉦た爛 爐項 / Net Amount to be paid by M.O. Accounts Officer 爐爐爐逗ぞ爐爐/ Date : ( 爐萎爐爐 爐爐逗爐爐鉦 爐爛 爐爛爐萎く爛爐 爐爛 爐朽げ爐 ) / ( FOR USE IN CASH SECTION) 爐爛爐 爐伍 爐爐爐逗ぞ爐爐 爐萎爐爐 爐爐項 Paid by cheque NoDate Vide cash book 爐爛 爐爐鉦い爐 爐伍爐爛爐爐 -10 爐爐 爐逗ぞ爐 爐伍爐爛爐爐 .................................................................................... 爐爛爐朽ぞ爐萎ぞ 爐爐爐爐 爐爐爐 爛 And Account No.10 Debit item No. --------------------------------爐爐逗.爐爐爐. / SS -------------------------------------------------------------------------------------- 爐.爐/ A.PFC.---------------------------------------- 爐爐爛爐爛爐朽爛爐むく爐鉦 / REMARKS ____________________________________________________________________________________________________________________________________________ Claim ID/爐爛爐爛爐迦爐 爐爐.爐÷. (for official use/爐爐鉦く爐鉦ぎ爐迦く 爐爛爐萎く爛爐 爐項爐む ) 爐踱 爐萎爐爐爛 爐爛 爐萎じ爛爐爛 爐爐逗爐 爐踱逗 爐項じ爛爐むぞ爐爛爐劇ぐ / 爐伍う爐伍爐 爐爐 爐爐鉦爐爛爐爐 爐朽た爐謹イ爐 Affix Re 1/- Revenue stamp & signature/thumb impression