ONLY * Marked

EMPLOYEE PROVIDEND FUNDS ORGANISATION *Mobile No : Mandatory to be

filled by Employees.
COMPOSITE CLAIM FORM (NON-AADHAR) *Employee Code :

FORM 19 - (PF FINAL SETTLEMENT) /10C (PENSION WITHDRAWAL BENEFITS) / 31 (PF PART WITHDRAWAL)

1 CLAIM APPLIED FOR: i) FINAL PF SETTLEMENT () , ii) PENSION WITHDRAWAL BENEFITS (), iii)PF PART WITHDRAWAL ( )
2* NAME OF THE MEMBER:(IN CAPITAL LETTERS)
(should match as per ALL records
Company Records, Pan card ,
Aadhaar Card and Cancel Cheque No Discrepancy )
3
A):UNIVERSAL ACCOUNT NUMBER (UAN) a):

B):PF ACCOUNT NO. (IN CASE UAN NOT AVAILABLE) b):

4* AADHAR NUMBER (FOR SEEDING):

5*
A) FATHER'S NAME a):

Or B) HUSBAND NAME (ONLY for MARRIED women

b):
employees who has changed named after marriage)
6* DATE OF BIRTH(DD/MM/YYYY FORMAT according to pan card & / /
aadhar card):
7
DATE OF JOINING THE ESTABLISHMENT : / /
8 DATE OF LEAVING SERVICE: (NOT REQUIRED IF APPLYING FOR PF PART / /
WITHDRAWAL)

9* A. PERMANENT ACCOUNT NO.(PAN) :

PLEASE ENCLOSE TWO COPIES OF FORM NO.15G/15H Yes
B. REASON OF LEAVING SERVICE:
SERVICE TERMINATED ON ACCOUNT OF (A) ILL HEALTHOF MEMBER

(B) CONTRACTION/DISCONTINUATION OF EMPLOER'S BUSINESS OR

(C)OTHER CAUSE BEYOND THE CONTROL OF THE MEMBER

Resigned
Perosna Reasons
SR.No. PURPOSE OF PF PART WITHDRAWAL
10 (A) PURPOSE OF PF PART WITHDRAWAL:(TICK WHICHEVER APPLICABLE)
1 HOUSING LOAN/PURCHASE OF SITE/HOUSE/FLAT OR FOR CONSTRUCTION/ADDITION,ALTERATION IN EXITING HOSE/REPAYMENT OF
(B) AMOUNT (IN RS):
HOUSING LOAN (PARA68B/68BB/68BC)
(C) FOR PURPOSE OF SITE/HOUSE/FLAT OR CONSTRUCTION THROUGH "AGENCY" OR REPAYMENT OF HOUSING LOAN OR LIC, 2 LOCKOUT OR CLOSURE OF FACTORY(PARA 68H)
INDICATE CHEQUE TO BE DRAWN IN FAVOUR OF AND PAYEE'S ADDRESS.
3 ILLNESS OF MEMBER/FAMILY (PARA68)

4 MARRIAGE OF SELF,SON/DAUGHTER/BROTHER/SISTER (PARA 68IK)

5 POST MATRICULATION EDUCATION OF CHILDREN (PARA 68 K)

6 NATURAL CALAMITY (PARA 68 L)
7 CUT IN ELECTRICITY IN ESTABLISHMENT (PARA 68 M)
8 ADVANCE FOR PHHYSICALLY HANDICAPPED (PARA 68N)
9 ONE YEAR BEFORE RETIERMENT (PARA 68NN)
10 INVESTMENT IN VARISTHA PENSION BIMA YOJANA (PARA 68 NNN)

11* BANK ACCOUNT DETAILS FOR PAYMENT:

Savings Bank Account No:

(PLEASE ATTACH A COPY OF CANCELLED Name and Address of Bank:

CHEQUE / Self ATTESTED COPY OF FIRST PAGE
OF PASS BOOK or Bank Statement if No name
printed on Cheque)
IFSC Branch Code :

12* FULL POSTAL ADDRESS (Employee)

PIN:
> THE MEMBER HERELY DECLARES THAT HE HAS NOT BEEN EMPLOYED FOR TWO MONTHS ( YES  / NO  )
> CERTIFIED THAT THE PARTICULERS ARE TRUE TO THE BEST OF MY KNOWLADGE.
> IN CASE THE AMOUNT IS USED FOR ANY PURPOSE OTHER THAN STATED IN COLUMN(10) ABOVE, I AM LIABLE TO RETURN THE ENTIRE AMOUNT WITH PENAL INTREST.

*MEMBER'S SIGNATURE (EMPLOYEE) EMPLOYER'S SIGNATURE (Company) DESIGNATION & SEAL OF EMPLOYER