RmrEs BoA, AD okacaw — OBO actardt afaer far atat - 1952 EMPLOYEES’ PROVIDENT FUND SCHEME, 1952 RACES dA AH chacws, 19525 yc Robe, seixc Baa AD Savors, fohes evaiohecnseiemenas yxy, (meg aon-72(5)) coe % Weto TVMOLAENERN SOS Sa er aren [PP Sache Hosen acho ES 419 a es SUPPLIED FREE OF COST [ACE S058, Sn FORM Foroffice use only _ars eteat Inward No, srt ft FARR ana 1952. a eet grat wftoe RAY awe a yt webeTa wee wT maT (Hr (72) 5) FORM TOBE USED BY A MAJOR MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEMES.1952 FOR CLAIMING THE EMPLOYEES’ PROVIDENT FUND DUES [PARA-72(5}] (Haws : 8 BE, Yor Habe aos, Xeusridm, aydsoror Lao) a wor at wed a ued Hom areata arash a oie aa ah ene tas fate wer argue gta (Read the Instruction carefully before filing ofthis form) (Allcorrection/alteration should be attested by the employer's) L AOA sats (2B egonea) get wr ary (312 seiet Name of the Member (in Block Letters) 2, SoBfecod BaoYSIOD Pics Oewts yomNGD)| ‘er ar are afer aT (Fanta eft ert oz) Father's Name : Husband's Name (incase of married woman) 3. ADA & Bod MdasIIgE, mars / Mosc BA she Owes aca & qd eye sree fee at a a oT f Name and Address of the Factory / Establishment } in which the member was last employed = - 4, a8 Hoss, TAT H.aaT HeIT Code No.Account Ni 5. eSobsy, mt ORF a1 wise 1 FATE / Date of Leaving Service 6, Aedonmy, naw more tat Btet TH ATE / Reason for Leaving Service 7, Sarr wod apex (BA exsRva) Br aw yer (12 start 4) Full Postal Address (in block letters) Se /Bess posieo pt pte ag at / SriSmt Kumar (230 Sores sorb ATA / Slo Wio/D/o) aa far PIN [ 8, GUmMD Sms FSM FT THT Mode of Remittance | Sok, BAG wosreciaeit W roca, ato waft sted Yarra Puta tick in the box against wy) Sescmapiod | ©) Sage DUFAO acinaro’ aaeoe GAGS Ho, 79 Sod SeAws Oe (85, 2,000/- Siéns aesarert a3) carson 1oeaeiateat va oe! st) aro &t ort oerrter grer( eae 3200074 Fa) = A) by Postal Money Order aay cost mate tRs2009] [] tothe adrossgivn in tem No.7 ony)2 &) Sak Rants soln Sem as, evoRod mow anst (VmAAUs mos jeord seo) wre BoE Sag Has chevt ampictede mow sas cworig OdOode, a send aod. oa) gh en ant diet ad ate tptorer Cagytts Talay oe) oh set ee fie Se-eiic er aege b) byAccount Payee Cheque sent direct for credit to my SB Alc (an luled Bank/Post Ofice/Co-operative Bank) under ikimaton ote (Avene plmped eco! tricked bute fT comand Honi/ 4. # are FET SB. ACN tRCSS Bath/ Fe aT ATHY Name of the Bank. yess / wry Branch, spsded Rarer Oxo / aver a get TAT Full Address of the Branch... tse Code c) Ae tier wquet a Rt at, aa H Gaza wee By NEFT Payment to my SB Ale. through Core Banking Systom d) Mandatory : Please enclose attested copy of first page of pass Book / Cancelled MICR cheque leaf IE: DAUD, TON SOM ORES Sa MUG WPCA, WARMEST WOMOGN ONeomyeD, MAT hh it a Sr gps we Pe A cr ga et gS tae wR ay Pes grat agua a gM Ty wT Note : Please enclose xerox copy of first page of S.B. Alc. pass book duly attested by employer for ensuring the cheque reaches to the correct party. Sg Sarg had 3-0 Fae [organ eq Tt ae 8a GT aqeIe Form SA for the current year sentlenclosed. and esi9ss decent Tq fata ae eT sierzrA Contribution for the current financial year Toen aiwart Taeay Tact Ae TSE é Contibution |. pl othe Contribution [8 a} 28 soso (Re sare [Se 5] a Bee see] El am SE ale creo) Palos 2 Bi Benos ot lawatertn| OB} Pen 3 | "breaks, PF olfeence | *2 reeks, Fan canon tfany Tar GER semaines, we Fy March pal nae ‘ = sire August Less. snersd comstinem woh @ mt Sh fb pid in Zea] ise fers § Sep we] Oct. FORM NO.5 5 Foaty | Total period of Remarks -Pravions Ne. No. ae] remgatne [abot estyloue], | Sen mare! | eae son, [unl guanar al pus 82] go BeBe | eogea,es on, [|B @ ree ese Pn Reg har ot member ining fund| family pension fund) Se FORMNO.10 Nante ofthe Em Falher name (or Husbands | Dalz ofleaving | Reasop of Leaving | Remarks AS] “*ti Blk uetee ‘lome!in'dace’of mated 'Sevees Sone 8(aaa Retr arr argentina Prater we Bee ert) (information be furnished by the Employer ifthe Claim Form is Attested by the Employer) Certified that the above contributions have been included in the regular monthly remittances. srg Pr ar soa stars ay fe aes den eee Fear me | etre aA, Good xb SmamA(S) dehy Lam) artes a2 ant gener / atyer ert area B ‘The applicant has signed/thumb impressed before me Bmdets / Polerwts wOMo xe Lomdaconr ORE 3 /ese noryaai, sees he fratore ar srftrge awit a gees ‘aren ar wee f ant ang ee & sis on SignatureofEmployerAuthorsed Offcalwithrubberstemp Signature/LefURight Hand Thumb Impression ofthe Member Ft Name 2 Omot feri# Date 9.f.AraT @ PF A/c. No. KN / Sod, shay dosed Teart a ater Designation & Seal ‘Sits gt WaT DECLARATION OF NON-EMPLOYMENT SPIos GaAAO okeresd 1952 som 69 eustees (1) TAMON (a) mos wvet¥ese (2) syReN (E)OR Roby etirrivm, shoamamOd AoYm mond exmS outset xoPObS Avosd Aco AMomMES BEEQ eros, Hox nip adc gone Sos momRsErh, Saft, atorat 1952 % seqede (1)a eer (Ht) se arqeee 2) at rer (f) 3 stanley gman By at at eT Sem ER, tre srr or or Sar weet me rene ete wa we aT Ae are ME TT wore Note : In the case of submission of application for settlement under clause(e) of ‘sub-paragraph (1) and in clause (2) of Paragraph 69 of the EPF Scheme, 1952, the claim should be submitted after two months from the date of leaving service Provided the member continues to remain un-employed in an estt. to which the Act applies PRAT Date 2 eeeeecsecenie eee a eemeveRt / ant ae ar sist one Signature/Left/Right Hand Thumb Impression of the Member wf @u wie / eomhebe wchacs ey eons c2e3 / ADVANCE STAMPED RECEIPT (8 8 (@) xongrag amg Lonedees) Sam avtar acth amt Tee Fe f | (lo be fumiced only in case of €(0) above) ae sate a ara tera eer Hore aa Be eT HT aA arr Seat a AA rae / TAT aA AT, 8 WOR AD GomNEDMODrRO LOMO. aaood da. al BTR. BR, 2.0%. andod© wrobsmn may xdodes, Received a sum of Rs... (Rupees... from the Regional Provident Fund Commissioner/Otficer-in-charge of Sub Regional Office. Provident Fund Account (anrish, <0 29, GOH dO Hoong Gor SREAET) (ea ore AY are ater are fe wher fay sates grat eT oT) nes The space should be left blank which shall be filed by Employees Stamp peenicent: bunch Oe a. 1-00 Xomob tito sks si wee oor, eeu ome sme ‘Feet aT cere EME TT aT eT ‘frat SIGNATURE/LEFT/RIGHT HAND THUMB IMPRESSION OF THE MEMBER ON THE REVENUE STAMP Affix Re.tes ara * aratea # saatt ® fez / FOR THE USE OF COMMISSIONER'S OFFICE Sear ar ste gol: Frere fear sear reat At wah es 21 (=) 24/2003 Pate a aT | Account Settled in Part/Full entered in F.21A/24/2/9 and Withdrawal Register farfire_Clerk aa. SS. (BF Cad Under Rs... eran | aa M.O/Cheque. Passed for payment for Rs..... sein words)... =e arte #1 (are Fo et at) M.O. Commission if any...... aaa gre 2a stale Net Amount to be paid by M.O. feet aenfrerdiaa Rat Date Accounts Officer/APFC_ ‘dee agurt avatr % fare / FOR USE IN CASH SECTION Ara ge (Fs) Bar HOT FAA AE FET AR ned FT, aver pra & fe aff | paid by inclusion in cheque No. -.mndvide Gash Book (Bank) Account No. 1 debit item No. a argurr wider arenfirerty cw ss AO. AP.F.CIR.PF.C. areyfteaty REMARKS ovat sift gE) ‘Acknowledgement Regsived on... amt arearfite fazer | Verified on...