ote Name EMPLOYEES’ PROVIDENT FUNDS ORGANISATION COMPOSITE CLAIM FORM (NON-AADHAR) (Crom nO. 12 (PF FINAL SETTLEMENTD/10¢ (PRYSION WITHDRAWAL BENEPITS)/34 (PF PART WITHDRAWAL (ick whichever is/are apple) Final PF Settiement (Pension Withdrawal Benes y TW) PF PART WITHORAWAL (J Name ofthe mentbec(IN CAPITAL LETTERS) ‘Universal coun Number UAN) 1): PAF. Account Non case UAN not available) FE be ‘ada Tarber (lor seeing): 3) Fathers Names by Hustoncs Name: Date of Date of fing ie absent ‘Dae of leaving sevice’ (vat required plying for PF Park Witarawal) '@) Permanent Account No (PAN): (Only n case 6 sevice es than 5 veer) (Pease enclose two copies of Form No. 156/15H, applicable) 'b) Reason of leaving Service: ~ Service terminatad on account of (a) al health of member (0) Contraction Discontinuation of employers business or (e) Other {Cause beyond the control ofthe member + Personal Reasons 0 2) Purpose of PF Part Withdrawal: (Tick V whichever aplcabe) b) Amount (n Rs 9) For purpose of Ste/Mouse/Flt oF Construction tough “agency” or Repayment of Housing Loan or LIC inate cheque to be drawn = In fovour of and payer's adress, a Purpose of PF Part Withdrawal | T | Fousing Loan Purchase of stetouse/Fat or for Constucion/Adltion, alteration ia ‘esting house/Repayment of Housing lan (Para 688/6068/6580) Ti _| Lockout or dosure of factony (Para 63 | Thess of member family (Para 65) TW ]artiage of” sot/sor/caugheer/brather sister (Para 68K) V JPost Matriculation education of here Para 684) ‘| Natural clarity (ara 68) We [Gut in electicty in estabichment (Pare am) Wa [Aavarce Yor PRYSaly handicapped Pare at) ‘| One year beter rternent Para GN) 2X PInvestment in Varta Penson BimaYojena Para. GENNN)| 7 Bank Account Baa Tor payment (Pease attach a copy of canceled chequeattestes copy of fst page af Pass Book). ‘Saving Bank Recount Wo Names. address ofthe Bank 1S Coe z Fal Postal ress Pn. ‘The member hereby declares that he has nat been employed for we months (Yea/.) Corti tht the particalars are true tothe best of my knowledge. [In case the amounts used for any purpose other than stated in column (10) above, Iam able to retum the ene amount wth pe interest. Members Signature Employer's Signature Designation®. Seal of EmployerINSTRUCTION SHEET FOR FILLING THE COMPOSITE CLAIM FORM (NON-AADHAR) 1. Purpose of advance & documents required: (The purpase may be one ofthe folowing): ) ip ii) ”) y) vi) vil) vill) co) Housing Loan/ Purchase of site/house/fat or for construction/ Addition alteration in existing house/Repayment of Housing loan: No document is required. New Declaration Form/Utlization Certificate required earlier has been discontinued. Uilness of member/family: |) Certificate of doctor and il) Certificate by employer that ESIC facility Is ‘ot avaliable to the member may be submitted by the member. Marriage of self/son/daughter/brother/sister: No document/Marriage Card is required. Post Matriculation education of children: No document is required, Lockout or closure of factory/Cut in supply of electricity: No document is required Natural calamity: No document is required. Purchasing equipment by physically handicapped: Medical certifcate is required. (One year before retirement: 30% of total PF balance can be withdravm. No document is required. Investment in Varistha Pension Bima Yojana: 90% of total PF balance can be transfered to LIC. No document is required. No Revenue stamp (Re. 1/-) is required to be affixed by the member, Income Tax (TDS) is deducted the service is less than 5 years (60 months), No Income Tax (TDS) is deducted in ‘ase the total balance is less than Rs. 50,000/-. However, TDS Is deducted @10% if the member submits PAN it ‘such cases. In case PAN is not submitted, then TDS @34.608% is deducted, ‘The total service in the present establishment as well as previous establishment is counted and, therefore, it is ‘advisable to merge all PF accounts. Pension Withdrawal benefits can be availed only Ifthe service is less than 10 years.