'::J;j~'-I' :;~c; -:~':...:-..;'::;":::5:I (NI~~I.j -;{. a~~~ ;50. Regn.,No. 66~~ 19:;' ~.19i . ""'. . " . fORM 19. . .e~~ID~ ~~~f$~~li;~~~, ;J;9~<:::;; ~~fufu~~q~~ EMPLOYEES' PROVIDENT FUND SCHEME, 1952 '''\ f1Jt)ds KJeJ&fa)~:041 QjLD~nfueJiJ ;illaillJ~&fis(jJ~\ ~41:Oamo1SJro~@QjOlJiJ f')o~ tj~&ru~ roJ[J() -72 (5)) Cfi. ~.-R.WI m ~Cqn 72(5)) ~4~ID<qff.f~m~-P:ft~-;n 52 ~ ~ ~"fflT ~ ~~ l:fiTtf FORM TO BE USED BY MAJOR MEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME '52."FOR CLAIMING THE EMPLOYEES' PRQVID~NT FUND DUE lPARA 72-(5)] I Employee- .--'--' (() , Employe(~ ~-w~~ ~e!o-WoQ pqm 3r¥~r ~ Refer to INSTRlJCTIONS 1. :0~P tb.J (:Je :Je ~~0'C)6') .~ Cf)T~ (~31oo iT) Name of the member (in Block Letters) a) "'°(9 tb.J I ~ Cf)T ~ I Father's Name b) <;5~tb.J I 1:ffu Cf)T~ I Husband's Name .Ri;Jx6-'i ;04b~G ';),:,);3;,;);;) 'iO'~lI"b;Jx / ;00:--,;) ;:)b.J.;)";Jj> Cf1TH§HT l'f~ ~ ~ C! 1rar,fuWt ~ 3'ifuQ qr{ ~'m Name& Addres>iof the FactoryI Establishment in which the memberwas last employed. $" Ei" :~o.. ~0" ;00<;P~ /~ 'B., '@1(ff 'B. C0de No., Account No. 2, 3. . 4. 5, .t5'Si\:;):.) ;Ji:)v:~ 06 /~ ~ c8~ I DateofLeavingService: 6. G5'Si\~ ;Si:)iD;;) ~bc.>;Jx ~ ~ Cf)T ~ I Reason for Leaving Service: ~/ ~;:).;)<.iJ /Sv~5/.m/ ~ I~ I Sri/Smt/Kumari .... TT jqr;ft l:rft S/o. W/o. 0/0. , , .." ...". ........ ~6~.:o e.:>~0'<:)5"~e ;:)b.;),:y;Jj> Full Postal Address (in Block Letters) .' ,... ...". , , , .... .,...,'...,..,."..".,., , "..:: ,...,..., "..., , , ',""'''''''''''''''''''''''''''''''''''''''''' fi:R/ Pin... ..\., ,..... ;7~~ ;Sgo~;J<:);,;),~ ;)i;);k ~~6' =~;;),';)g<.iJi! r~~0o~a;;).;). i:f1G!..f c8 fc!fu~ f<tm ~..~ I:f{ ~ iT(fV:!»~ Mode of remittance Put a tick in the box against theqne opted a) ,:y<;pb.;)j5' "'~<:);:).;)~o'5.J>gw "'jO'~;;' 7 S~Wll" =~;;,~w.;)"~ / ift:~ I:f{11itWJ\ IDU"R..B'&n 7 it ~:rrq~ ~ TJit ~ I:f{ By postal money order at my cost to the addressgiven againstitem NO.7: r / I b) ,'3'~ <3VM~b.J;~.;)" ~;)of;' <J'$OSv~<iJ'5" (~~$...6 <J'.,SoSv~.s.) ~~ 'i~Q~3:5W"'i" ~07: ~)~ow~o.:.;, '3SvI:-W'j0' ~~~~ijhFm'@1(ffR,iI~~~(~~/~;mm~"~) I I By Account Payee Cheque I through Electronic C!E)~ralJceSys,tem (ECS) sent c':ect '. for credit to my S.B. Ale. Scheduled Bank I Post Office) under intimation: 2.?~0!:i; ~w/ ~ Cf)T ~ I Name of the Bank ;, """','''''''''''''''''''''''''''''''''''''''' .J":;P / ~ I Branch : """""""""'::.""'" :.:: \: ..".., ..)S.iJ. "'~oS:5o./~ ~ '@1(ff-;{./ S.B. Account N() 7. 8. S.B, Ale. No. in words .J":;P~~ ;:)b.;).;)";Jj> I~ Cf)T ~ -q(i[ttR ~ ~ I Full Address of the Branch 'lo~ ~owo,:) ~~~lI" ~jc:j~~ ~;Sj~O/,~ ~ mR ~ eftTltf AdvanceStampedf1eceiptfurni~hedbeI0w.. . .II~ -_.,~-- --'--'-' -- ~Pin Code :~.._._-
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;7~~ ;Sgo~;J<:);,;),~;)i;);k ~~6' =~;;),';)g<.iJi! r~~0o~a;;).;). i:f1G!..f c8 fc!fu~ f<tm ~..~ I:f{~ iT(fV:!»~Mode of remittance Put a tick in the box against theqne opted
1f11! ~'mn j ,".c:;. ,:,,' "'i;'q;.~..~i mtr'f.tfu~ ,itfft)/ 3f'l.~'Cfil.'q.''1.j ~~-r.rm j. period of
M h EPF difference Pension Fund Ref. of . Remarksont Amount of EPF 10%& Contribution Advance ;?;r
Wages '8.'/,'10 or 12./~ & 8-1/3% No. of iJays( con n .u 1098'/ % servIce
, ~~ ~~1 2 3 4 4b 5 6 7
March paid in ',-\ ' ,', -'0,."
Aprilj1fT'ii 'o/T ~~ "-- - -- (a) -:fIcntT~~ ~~
;;p IJune f.ffu ~--~ -- ~m;it~ /July Dateof
~ leaving-~1lT({.!Aug~- service, if
~ 1 September any.-- -
~y-n 1 October --,--
;pj1."iif1:/ November
~ I December ~ - (b) ~, ~q;f
~ojcl~ I_~_anuary , <nroJT <i'fu
'PCIil I Februarv ---~-- ~ m ;it-- : :._- 1 -- Reasonsl:f;<.-.::rR)Ii '1'['1/ for
February paid in Marcil "4" leaving-" service. if
¥'I/ TOTAL any.
FORM No. 5
FORI~~'N9. 10'
A/c.~o. Name of the employee(in Block Letters)
Father Name(or Husb,and's Name incase of married women
Date Qfleaving ,
ServiceReason of
LeavingServiceRemarks
~.'
Date:~wpr 3!1~.ctIl(I~~'~:I~ !"' /,:~~14'1~.~ ~
Signature of Authorised Official: Seal;bfthe' Establishment~
Remarks:Date of
Total period of PreviousAle.eligibility for previous No.and
particulars ofnew member I servicepreviousFather Name
Date of date of joining (exclusing employer,anyName of the employee (or Husband's Name BirthSex t/)eEstt. in' It period of, (ifso whether,
A/c.No.(in Block Letters) in case of married cseot'old"
breaks) as on he is a memberwomen member the date of of familyjoining fund Pension Fund, .
aiso)
.
I'
-it ef->.[ITt :r m * ~DECLARATION OF NON~EMPLOYMENT
11~ CRCn~fc!;1f.t~ ~ft<n~([211 ~ f.rf4\Tfucfit31Rfqqm:fi %\1311ifi8,{;TW'9.fB "frmm ~cf2 1110cfit~q ifM ~ ~P'H'FITit ~ ~fCrRrf.'rft!31R~ ~ it. q;m~ R;qr~ I ,
Ideclare thai Ihave resigned and not employed)n any factory/ establishment to whichthe E,P.F.Scheme applies forH)f"continuous period of not les's than 2 rr,onths immediately preceding the data of my application'for final withdrawalofi;lV provident fund money, "
~mm GrC11~ ~I~(JII/ DECLARATION FOR UCD CLAIMI further declare that I am a reaiclaiment and could not apply immediatlytill now due to my personal reasons.fj 31r11~ cg(jl' t fc!;if 01mft~ t 3fR if 0<.Jfif(fT!(fC\1RuTIB ~i8 (f0'fk! ~ HGt-:Ti '
;~Ou~~ ~Ci :JG:O: / ~,c ;SO):5"w;:\~~ ~If? /'JG,B:r1; 6«!T~ 7:fT<rru,/ ~, o!?T1; ~ q;] f.mRSi~Jnatureor Left / Fiight hand thumb impression of the member
91'1\ 0\ mH'1<\10erF\H 0111?J~lFn
,:;ob.;c.; ,:y' ')b;u ;>c<i:9~;i)j,,",,w / :5"w~ ~~~t5 j<'gVw.This applicant has signed /thuml: impressed before me.
f~::rir:fi j[)
Date
~m "~:o,3If~if;~&t'"'r""~'"", ", , '," ""
:;::,C) :::b::5wG,::5w
2.i;~~p & 6~S"'b:JJ~wc~ ~t;)zoO~o~~~
Signature of the e!T!pl()~~rq! <;!uthoriseg'official~ ~ ~"'~CJO;'~O<fu ~t5
,ieceived a sum of Rs, """"."".""." , (Rupe8s ".." only)iromFiegional Provident Fund Commissioner/Office-in-Charge of my Provident Fund Account'f deposit in my Savings Bank account towrd the settlement of my Provident Fund Account.
'FfT3m. >rqlU1'Bf~ mmt ~ ~ ~ ~Are you willing to accept withdrawal benefitOR Scheme Certificate(Put a tick (v"') in the concerned box)~~O&) ;)~~~ t'<fJ"{jd~~ ~e~ ~~w, ~~~ t~)
-qfufT(if; fcr<Rur (cffir <IT'f(';f'r (1m ~ ~~)Particulars of Family (Spouse & Children & Nominee)
8.
9.
\
~5 ~~ ~o./ftR/PIN :
~~;6o~tiM ~03J0!::j~~mmt~
Withdrawal Benefit
D
~~~o ~~~~o.~Scheme Certificate
D
~~ l;:wr I Name
-"
~~;::)sa~ fctfu
Date of Birth
'::>~i?& ~~~ '::>oo~~ ~.J1"f1~ct>if; m:~
q)f ;rrqNameof the
guardianof Minor
oJ) ~:x,'b/ ~ I Nominee
{)) ~W02J. ~~S<W
q; ) <rftcm:BGflI.a) Family Members
l'ie:> '::>02J0,;50
~ it B<siqRelationshipwith member
,
..
2
o. ~Q..).;)~~~:?~ ~~o.> ~~~ ~oa 58 ~~o-~;S~ 'o-~~ ~~~~~ ~t!~~ ~ol8S~J°5' :58~ ctT~ c);~ -en~ 'en)~ fuRnm:<fC6t~~ -en':Incase of death of member afterattainingthe age of,58 years~withoutfilingthe claim:
. - wr)~ ~f.Ifu ~ / ~ ~~it mntt~wu~~f.@nmitit f.t1R:~it <i>RUTm ~ ~ @it ihmr it ~ 1)meaf<8n I
Received a sum of Rs. ( Rupees
only from Regional Provident Fund Commisioner / Officer-in-charge 01Sub-Regional Office
by deposit in my savings Bank Nc towards the settlement of my Pension Fund Account.
~ObM i;5:>~;)t;J~~~bJ / e.s~bJ9~>7~~ o~~ ~b;J ~.¥~~.(W~citwrBt~W ftm~~f.Ifu~ /~~IDU~~)(The space should be left blankwhich shall be filled by Regional Pravdent Fund Commissioner / Officer-in-charge).
(18lf 3 Cfi/7 (t<ft.~.)~~CfiT~t ~~<!>T~~f.Ifu~q;)11ffi't~1TTJ:~)(Form 3 A / 7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund Office)
~6\~ ~t)0 ~v;:s ~8 ;J1'ws jl1§;J1'D)~ M
~ ts:;r <tIfufucfr~Wages as on the date of exit I leaving ,
~]5-]]-95CfiT~ (l@ ~ + ~~~) (WR"Rf1Lm)Wages (Basic + DA) as on 15-11-95 (if applicable)
~V"v 0 "300.;;5;)~6\~ ~e;oM ~
~ircn<tl ~
~ /
Period of Non-contributory Service (Breaks in Service) ,
~~~~Ju0 ~~C?1 g<:f /_liNl Year / Month
5" ~~~o~~ R;fLcfr<ci~IL No. ()f DaysParticulars of Breaks month-wise should be furnished in
a separate statement Le. From Date of Joining to15-11-1995 & 16-11-1995 to Date of Leaving Service.
D.O.J. to 15-11-1995
~16-11-1995 to D.O.L.
..
4.
~O@o'5J~;J / ~~~)~ ~t;J~C ~O.u~O
~/~<h~~I~~~1
Signature of Employer I Authorised Officialof th~ Estt.with Seal & Date