PF Withdrawal Application (Sample Copy)
PF Withdrawal Application (Sample Copy)
PF Withdrawal Application (Sample Copy)
7. Full Postal Address (In Block Letters) No 480 2nd Cross, Prestige Apartments
Please furnish correct address/information West of the chord Road, Rajajinagar
Bangalore-560036 Present Postal
Address
Date of Birth
Date of Birth/Age 12 .01.1983
Date of Joining Establishment 10.03.2003 Date of Joining
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.
Signature of the central Spoc with the Authorization seal Signature of
the Employee
Date:
Signature of the Employer/ Signature/left hand thumb impression of the
Authorized Official with rubber stamp Member
___________________________________________________________________________________________________________
Declaration of the Non Employment
Note : in the case of submission of application for settlement under clause (E) of sib paragraph (1) and in clause(2)of
paragraph 69 of the EPF scheme 1952 , he claim should be submitted after two months from the date of
Signature of
leaving service provided the member to remain un-Employed in an Est. to which the Act applies.
the Employee
_____________________by deposit in my savings bank account towards the settlement of my Provident Fund Account.
Affix Re.1/-
The space should be left blank which shall be filled in by Revenue
Employer Provident Fund Office. Stamp Signature of the
Employee (No need
Signature/left hand thumb impression of the
to paste the
member on the Revenue Stamp
revenue stamp)
FOR THE USE OF COMMISSIONER’S OFFICE
Account settled in Part/Full entered in F.21/A/24/2/9 and withdrawal register
Clerk Section
Supervisor
__________________________________________________________________________________________________________
Under Rs.___________________________________________________________________________________________Only)
EE ER TOTAL
Interest up to
Amount Authorized
Date : A.A.O/A.P.F.C
FOR USE IN CASH SECTION
Paid in inclusion Cheque No ____________________________________________dated_____________________Vide cash Book
(Bank)
Account No 3 Debit Item No.
C.W S.S AAO
A.A.O/A.P.F.C
Remarks
Acknowledgment received on __________________________________________________Verified on____________________
Form No 10-C(E.P.S)
Name of the
1 (A) Name of the Member (In Block Letters) Mukesh Bhatia Employee
PF Number
Date of Leaving
6.Reasons for Leaving Service Resigned
& Date of Leaving
14 10 2009
Present Postal
7.Full Postal Address (In Block Letters) No 480 2nd Cross, Prestige Apartments Address
West of chord Road,Rajaji nagar
Bangalore-560028
Sri/Smt/Kum Put a right
S/o.D/o.H/o.W/o mark
inside the
box
Leave blank
9. Particulars on Family (Spouse, Children or Nominee)
(B) Nominee
Leave Blank
10 Incase of Death of the member after the age of 58 years without filing the form.
(B) Name of the Claimant(s) and relation ship with the member.
____________________________________________________________
11. Mode of the remittance (PUT A TICKET IN THE BOX AGAINST THE ON OPTION)
Leave Blank
The space should be left blank which shall be filled by this office
Affix Re.1/- Signature of
Revenue the Employee
Stamp (No need to
paste the
revenue
stamp)
Signature/left hand thumb impression of the member on the revenue
stamp
Leave page blank
Certified that the particulars of the member given are correct and the member has signed/thumb impression before me.
The details of wages and period of non-contributory services of the member are furnished under Form- 3A/7(EPS) enclosed
for the period for which was not sent the Employees Provident Fund Office
Date of Joining