Form No 19

For Office Use Only

Inward No.
EMPLOYEES PROVIDENT FUNDS SCHEME 1952
FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEMES,1952 FOR CLAIMING THE
EMPLOYEES PROVIDENT FUND DUES(PARA-72(5)).
(Note: Read the instruction carefully before filing this form)
(All correction/Alteration should be attested by the Employer)
Employee
Number
1. Name of the Member (In block Letters)
Mukesh Bhatia
Emp No _2072455
2. Parent Name (Husbands name in case of the
married women)

Name of the
Employee
Fathers /Husbands
Name

Ajay Bhatia

3. Name and Address of the Factory/

Establishment in which the member was last
Employed
4. Code No & Account No.

Will appix the company

seal
PF Number

KN/25075/40108

5. Date of the Leaving Service

6. Reason of the Leaving Service

7. Full Postal Address (In Block Letters)
Please furnish correct address/information

8. Mode of the Remittance

Put a ticket against the any one
(A) By postal money order at my cost if the amount
Payable exceeds Rs.500/(if the amount payable is
Less than Rs.500/ M.O commission will be come
by the PF Office. Payment Exceeds more then
Rs.2000 above will not made through M.O.
B By Account payee cheque send direct for credit
for the SB A/c any Scheduled Bank/Post Office/
Co-operative Bank) under intimation to me
(Advance stamped receipt furnished below)
Please furnish the S.B. A/c.No duly optioned in
any nationalized bank/Scheduled Bank/
Co-operative bank with the Full postal address
of the bank

Last Working day

14 Oct 2009
Resigned

Leave blank

No 480 2nd Cross, Prestige Apartments

West of the chord Road, Rajajinagar
Bangalore-560036
Present Postal
Address

M.O

CHEQUE

to the address given in Item No 7

S.B A/c no 0014690000321
E.C.S No
Name of the bank H D F C Bank

12 .01.1983

Leave Blank
Name of the Bank
Address of the
bank with the Pin
address

Branch Alwarpet Branch

Full Address of the Bank HDFC bank Brigade Mansion,Jeevan
Bheeema Nagar, Alwarpet Chennai-600012

CERTIFED THAT THE PATICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date of Birth/Age

Bank Account
Number

Date of Birth

Date of Joining Establishment

10.03.2003

Date of Joining

Date of Leaving Service

14.10.2009

Date of Leaving

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
Date :

Signature/left hand thumb impression of the member

ADVANCE STAMPED RECEIPT
(To be furnished only in case of 8 (B)above)

Received a sum of Rs.___________________Rupees_________________________________________

________________________from the Regional Provident Fund Commissioner/Officer in-charge of Sub Regional Office
_____________________by deposit in my savings bank account towards the settlement of my Provident Fund Account.
Affix Re.1/Revenue
Stamp

The space should be left blank which shall be filled in by

Employer Provident Fund Office.
Signature/left hand thumb impression of the
member on the Revenue Stamp

Signature of the
Employee (No need
to paste the
revenue stamp)

FOR THE USE OF COMMISSIONERS OFFICE

Account settled in Part/Full entered in F.21/A/24/2/9 and withdrawal register
Clerk
Section
Supervisor
__________________________________________________________________________________________________________
Under Rs.___________________________________________________________________________________________Only)
P.I No__________________________M.O/Cheque_______________________A/c N KN/BN__________________________
Section ________________________________ Passed for Payment for Rs._________________________________(In Words)
Rupess__________________________________________________________________________________________Only)
M .O.Commission if any _______________________________________________Date____________________________
Net Amount to be paid by M.O_____________________________________________________________________
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)
Employees Pension Scheme-1995
Inward No:

FORM TO USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME 1995 FOR

CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
(Read the instructions before filing this form)
1 (A) Name of the Member (In Block Letters)

Name of the
Employee

Mukesh Bhatia

(B)Name of the claimant (s)

Date of Birth

2. Date of Birth

12

01

3 (A) Fathers Name

Ajay Bhatia

1983

Will appix the company

seal

(B) Husbands Name (If Applicable)

4. Name and Address of the Factory/Establishment in
which the member was last Employee.
5.Code No & Account No

Fathers/Husbands
Name

______________________________________________________
__________________________________________________________
RO/SRO CODE
EST. Code No
A/ c no
KN/25075/40108
PF Number

6.Reasons for Leaving Service

& Date of Leaving
7.Full Postal Address (In Block Letters)
Sri/Smt/Kum
S/o.D/o.H/o.W/o

Date of Leaving

Resigned
14

10

2009

No 480 2nd Cross, Prestige Apartments

West of chord Road,Rajaji nagar
Bangalore-560028

Put a right
mark
inside the
box

8 Are you willing to accept Scheme

Certificate in lieu Withdrawal Benefits?

(A) Yes

(B) No
Leave blank

9. Particulars on Family (Spouse, Children or Nominee)

Name
(A) Family Member(s)
(B) Nominee

Present Postal
Address

Date of Birth

Relation with
the nominee

Name of the
the minor

Leave Blank

10 Incase of Death of the member after the age of 58 years without filing the form.
(A) Date of the Death of the Member
(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)
(A)

By postal Money Order at my cost to the

Address given in the Column 7
(B) Account payee cheques sent direct for
to credit to my S.B A/c (Scheduled Bank
to me under intimation to me

S.B A/c no

0014690000321

ECS Code No

____________________

Put a right
mark
inside the
box

Bank Account Number

Leave blank
Name of the bank

Name of the Bank ( In Block Letters) H D F C Bank

Full postal address of the branch
(In Block letters)

HDFC bank Brigade Mansion,Jeevan

Bheeema Nagar, Alwarpet Chennai-600012

Full Address of the

bank

Leave Blank
12 Are you availing under EPS-1995 If so Indicate
PPO No ____________________by Whom issued__________________________
____________________________________________________________________________________________________________
____
CERTIFED THAT PARTICULARS ARE TRUE TO THE BEST OF THE MY KNOWLEDGE
Signature of the
Employee
Date:

Signature/left hand thumb impression of the member/Claimant(s)

ADVANCED STAMPED RECEIPT
(To be furnished only in case of 11 (b) above)

Received the sum of Rs.____________________________________(Rupees________________________________only)

From the Regional Provident Fund Commissioner/Officer in-charge of Sub Regional Office, by depositing in my savings bank
A/c towards the settlement of my Provident Fund Account.
The space should be left blank which shall be filled by this office
Affix Re.1/Revenue
Stamp

stamp

Signature/left hand thumb impression of the member on the revenue

Signature of
the Employee
(No need to
paste 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
Wages (Basic+D.A) As on 15/11/95 (if Applicable)
Wages on the date of Exit
Period of Non-Contributory Services

Date

Signature of the Employer/ Authorized official with Rubber stamp

(FOR THE USE IN COMMISSIONERS OFFICE)

Under (Rs.____________________________P I No_________________________________ M.O.Cheque ____________________

Passed for the payment for Rs._________(Rupees)___________________________________________only)
M.O commissioner (If any) Rs.____________________net amount to be paid by M.O __________________towards withdrawal
benefit.
D.A

S.S

A.A.O

Paid by inclusion in Cheque No___________________________________________date _________________vide Cheque Book

Account No 10 Debit Item No______________________________________
D.A

S.S

AC (CASH)

S.S

APFC (A/CS)

For issues of S.S :IDS is enclosed

D.A

(FOR USE IN PENISION SECTION)

Scheme Certificate bearing the control no
scheme certificate control register
D.A

Issued on
S.S

and entered in the

APFC (Pension)