PF Withdrawal Form: (Employee's Details)
PF Withdrawal Form: (Employee's Details)
PF Withdrawal Form: (Employee's Details)
[Employees Details]
Name of the Employee:_____________________________________________
Mobile No:-
OHR id :-
Regn. No.
Pan No:Form 19
Application by an Adult Member of the Employees Provident Fund Scheme, 1952 for
Claiming the Employees Provident Fund Dues
(Refer to Instruction)
1.
8.
Mode of remittance
(a) By Postal Money Order at my cost
(b) By Account payee cheque sent
Direct for credit to my S.B.
A/c (Schedule Bank/PO)
Under intimation to me
(
(
(
(
)
)
)
)
Period of Break,
if any
Total
EPS
(Information to be furnished by the Employer if the Claim Form is Attested by the Employer)
Certified that the above contributions have been included is the regular monthly remittances.
The Applicant has signed / thump impressed before me.
...
Signature of Left/ Right hand thump impression of the member
Signature of the Employer or authorized Officer
Designation & Seal:
Date : .
DECLARATION OF NON-EMPLOYMENT
I declare that I have not been employed in any factory/establishment to which the Act applies for a continuous period of
not less than 2 months immediately proceeding the date of my application for final withdrawal of my Provident fund
money.
Date :
Head Clerk
AC/RC
Remarks
Mobile no
2.
Date of Birth
3.
Fathers Name
4.
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6.
7.
A/c No.
.
..
PIN .
(a)
Yes
(b)
No
10.
Date of Birth
(a)
Family Member
..
..
(b)
Nominee
..
..
..
11.
In case of death of member after attaining the age of 58 years without filing the claim:
12.
(a)
(b)
Mode for Remittance [Put a Tick in the Box against the one opted]
(a)
(b)
Account payee cheque sent direct for direct to my SB A/c (Schedule Bank)
Under intimation to me.
S.B. Account No.
Branch
(in block letters)
13.
Date:
Certified that the particulars of the member given are correct and the member has signed / thump impressed
before me.
The details of wages and period of non-contributory service of the member are as under:
Form 3A/7 (EPS) enclosed for the period for which it was not sent to employees Provident Fund Office.
Date: .
Signature of Employer/
Authorised Official
(
in
words)
D.H.
S.S.
A.A.O.
D.H.
S.S.
AC (A/cs)
D.H.
S.S.
A.A.O./APFC (A/cs)
D.H.
S.S.
A.A.O.
APFC (PENSION)