'::J;j~'-I' :;~c;

-:~':...:-..;'::;":::5:I

(NI~~I.j

66~~
.
""'. 19:;' ~.19i
"

.e~~ID~

fORM

19.

-;{.

a~~~;50.

Regn.,No.

.
.

~~~f$~~li;~~~,

;J;9~<:::;;

~~fufu~~q~~
EMPLOYEES' PROVIDENT FUND SCHEME, 1952
'''\

~\ ~41:Oamo1SJro~@QjOlJiJ
f')o~ tj~&ru~ roJ[J()
-72 (5))

f1Jt)ds
KJeJ&fa)~:041
QjLD~nfueJiJ
;illaillJ~&fis(jJ

Cfi.~.-R.WI m ~Cqn 72(5)) ~4~ID<qff.f~m~-P:ft~-;n

52 ~ ~

~"fflT

~ ~ l:fiTtf

FORM TO BE USED BY MAJOR MEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME '52."FOR

CLAIMING THE EMPLOYEES' PRQVID~NT FUND DUE lPARA 72-(5)]

~e!o-WoQ pqm 3r~r~

~-w~~
1.

Employee-

(()

Refer to INSTRlJCTIONS

.--'--'

Employe(~

:0~P tb.J (:Je :Je ~~0'C)6')

.~
Cf)T~ (~31oo
iT)
Name of the member (in Block Letters)

2,

3.

a)

"'(9 tb.J I ~

b)

<;5~tb.J I 1:ffu Cf)T ~

.Ri;Jx6-'i ;04b~G
Cf1THHT l'f~

Cf)T

I Father's Name

Husband's

';),:,);3;,;);;)'iO'~lI"b;Jx

Name

;00:--,;)

C!1rar,fuWt

;:)b.J.;)";Jj>

3'ifuQ qr{ ~'m

Name& Addres>iof the FactoryI Establishment

in which the memberwas last employed.
. 4.

$"

Ei"

:~o.. ~0" ;00<;P~

/~

C0de No., Account No.

5,

.t5'Si\:;):.) ;Ji:)v:~ 06

6.

G5'Si\~

'B., '@1(ff'B.

/~

;Si:)iD;;)~bc.>;Jx

~/ ~;:).;)<.iJ
/Sv~5/.m/ ~

7.

c8~

~
I~

I Dateof LeavingService:

Cf)T

I Reason for Leaving

I Sri/Smt/Kumari

TT jqr;ft l:rft S/o. W/o. 0/0.

,
~6~.:o e.:>~0'<:)5"~e
;:)b.;),:y;Jj>

....
,

.."

Full Postal Address (in Block Letters)

.,...,'...,..,."..".,.,

8.

Service:

"..::

.'
,...,...,

"...,

,... ...". ,

fi:R/ Pin...

, ',""''''''''''''''''''''''''''''''''''''''''''

;)i;);k ~~6' =~;;),';)g<.iJi! r~~0o~a;;).;). i:f1G!..f c8 fc!fu~

;7~~ ;Sgo~;J<:);,;),~
Mode of remittance Put a tick in the box against theqne opted

a) ,:y<;pb.;)j5'
"'~<:);:).;)~o'5.J>gw
"'jO'~;;' 7 S~Wll" =~;;,~w.;)"~

/ ift:~

...". ........

f<tm ~..~

I:f{~

..\.,

,.....

iT(fV:!~

I:f{11it WJ\ IDU"R..B'&n 7 it ~:rrq~

~ TJit~

By postal moneyorder at my cost to the addressgiven againstitem NO.7:

, ....

I:f{
/

b) ,'3'~ <3VM~b.J;~.;)" ~;)of;' <J'$OSv~<iJ'5" (~~$...6 <J'.,SoSv~.s.) ~~ 'i~Q~3:5W"'i" ~07: ~)~ow~o.:.;, '3SvI:-W'j0'
By Account Payee Cheque I through Electronic
~~~~ijhFm'@1(ffR,iI~~~(~~/~;mm~"~)

C!E)~ralJceSys,tem (ECS) sent c':ect

for credit to my S.B. Ale. Scheduled Bank I Post Office) under intimation:

2.?~0!:i;

~w/ ~

/~

Cf)T

I Name of the Bank

I Branch

..)S.iJ."'~oS:5o./~

~ '@1(ff-;{./

.J":;P

S.B. Account

;,

~~

'.

:.::

\:

.."..,

N()

;:)b.;).;)";Jj> I ~

.II~
Cf)T~ -q(i[ttR ~

'lo~ ~owo,:)~~~lI" ~jc:j~~ ~;Sj~O/,~

AdvanceStamped f1eceiptfurni~hedbeI0w.. .

I Full Address of the Branch

"""',''''''''''''''''''''''''''''''''''''''''

"""""""""'::.""'"

S.B, Ale. No.

in words
.J":;P

mR ~

eftTltf

-_.,~---'--'-'
--

~Pin

Code :~.._._-

.~

1f11!

,-~

,
""...,.",~
WORKER'S

..

ont

"""".'<

FOR, THE CURRENT FINANCIAL. YEAR

-

CONTRIBUTION

, """":,w:,.w"""",::",~,,:,~",,,,

~'mn

Amount

Wag es

of

==
,

paid

Aprilj1fT'ii

'o/T

"--

;;p

--~

==

,".c:;.
'Cfil.'q.''1.j

,:

-'--"

~qa
tf1':'4

mtr'f.tfu~

~~-r.rm j.

,itfft)/

EPF difference

Pension Fund

'8.'/,'10 or 12./~ &

8'/ %

8-1/3%

EPF

10%&

4b

',-\

' ,',

Remarks

con n .u 109
servIce

~~

-'0,."

- --

(a) -:fIcntT

~~

IJune

;?;r

Advance
No. of iJays(

3f'l.~

period of
.

Ref. of

Contribution

~~

..q''''M''~
..f.=>ri\Wii~
:wrl'q(~~..,

,:,,' "'i;'q;.~..~i

in

~~

10% 1\2%

R"~I~ 111 "'0('

' j
"','
EMPLOYER'S
SHARE

""0('
SHARE

1
March

Statytory Rate of
'Contribotjons
,.:,V"",\'" :

3i~I~I'"

~6.Jfu~~J..~o.~ goL~~ .s~~

f.ffu
~m;it~

--

/July

Dateof
leaving

-~1lT({
.!Aug~-

1 September

service, if
--

any.

~y-n 1 October
;pj1."iif1:/ November

--,--

I December

(b)

~ojcl~

I_~_anuary

I Februarv
---~-:._- 1
l:f;<.-.::rR)Ii '1'['1/
February paid in Marcil
-"
'PCIil
--

'I/

~
~q;f
<nroJT <i'fu

-"4"

TOTAL

m ;it

Reasons
for
leaving
service. if
any.

FORM No. 5

A/c.No.

Name of the employee

(in Block Letters)

Father Name
(or Husband's Name
in case of married
women

Date of
Birth

, .

Date of
Total period of
eligibility for
previous
new member I
service
date of joining
(exclusing
Sex
t/)eEstt. in' It period of,
cseot'old"
breaks) as on
member
the date of
joining fund

Remarks:
PreviousAle.
No.and
particulars of
previous
employer,any
(ifso whether,
he is a member
of family
Pension Fund
aiso)

.
I

'

FORI~~'N9. 10'
A/c.~o.

Name of the employee

(in Block Letters)

Father Name
(or Husb,and's Name in
case of married women

Date Qfleaving

Reason of
LeavingService

Service

Remarks

~.'

~
Date:

~wpr

3!1~.ctIl(I~~'~:I~ !"' /,:~~14'1~.~

~
Seal;bfthe' Establishment

Signature of Authorised Official:

-it ef->.[I
Tt :r
DECLARATION
11~

CRCn fc!;1f.t~

~ft<n ~([211

m* ~

OF NON~EMPLOYMENT

f.rf4\Tfucfit31Rfqqm:fi %\1311ifi8
,{;TW'9.fB "frmm ~cf2 1110cfit
~q

P'H'FITit ~

ifM

~fCrRr
f.'rft!31R~ ~ it. q;m~ R;qr~ I
Ideclare thai Ihave resigned and not employed)n any factory/ establishment to whichthe E,P.F.Scheme applies for
H)f"continuous period of not les's than 2 rr,onths immediately preceding the data of my application'for final withdrawal of
i;lV provident

fund money,

"

~mm

GrC11~ ~I~(JII/ DECLARATION FOR UCD CLAIM

I further declare that I am a reaiclaiment and could not apply immediatlytill now due to my personal reasons.
fj 31r11~

cg(jl'

t fc!;if 01mft~

t 3fR if 0<.Jfif(fT!(f
C\1RuTIB ~i8

(f0'fk!

~ HGt-:T
i

'

/ ~,c ;SO):5"w;:\~~ ~If? /

'JG,B:r1; 6!T~ 7:fT<rru,/ ~, o!?T 1;
q;] f.mR
Si~Jnatureor Left / Fiight hand thumb impression of the member
;~Ou~~

~Ci :JG:O:

91'1\ 0\ mH'1<\10erF\H

0111?J~lFn

This applicant

f~::rir:fi

:5"w~ ~~~t5
j<'gVw.
has signed /thuml: impressed before me.

,:;ob.;c.; ,:y' ')b;u

;>c<i:9~;i)j,,",,w

~m

j[)

Date

& 6~S"'b:JJ~wc~ ~t;)zoO~o~~~

2.i;~~p

Signature of the e!T!pl()~~rq! <;!uthoriseg'official

:;::,C) :::b::5wG,::5w

[",d

"~:o,3If~if;~&t'
", , ',"
""

"'r""~'"",

~"'~CJO;'~O<fu

~t5

Designation &Seal

3IfchdImFd Rlk / ~o~~

~~so.:J ~o~m

~~

(J&,~

ADVANCE STAMPED RECEIPT

(~~m

8 ('&) cfit ~TT if ft<n ~

I) ( 8 (f))

(;>~~

O:';:SJ;:S<:;o::i:.,),~
)

(to be furnished only in case of 8(b) above)

WR ~Lf-'!,'&1i't41R1RR ~ <itxR.311
':1.<101.<'\,'0,.,

"...".,

/ :;Pi~.31f~

,...,..,,,,..

'" .:.,..'"".

.'

.iifi1~~'i:Rf'~

.,

mm.'i~

,ieceived a sum of Rs, """"."".""."

,
(Rupe8s
".."
irom Fiegional Provident Fund Commissioner/Office-in-Charge of my Provident Fund Account
'f deposit in my Savings Bank account towrd the settlement of my Provident Fund Account.

:;tim ~fJ-:rf.rfq ~

/>r'l11D31f~ID\T

it; ~

only)

;on~rI

t>c2c:i: .;5;J~,Dy>j,~~::5w/
~ot>cili $;~zoO'0eJ~~~9~,y~Qo~W';v~~~) ;$C5eJ;sa~.
,"

[he space should be left blank which shall be filled in by Regional Provident Fund
Commissioner / Officer-in-Charge.

1 ~CfiT~WR

~
z..'ibv";J.= ro~$
i');:;\;5)
" ",,'::H~~
Affixe 1 Rup~e
Revenue, Stamp!

RtfiC:'q"{~<r if; ~& m ~/~

-m~if; Wr3"<filf-mFf
Signature or Left fRight hand thumb impression of the member on the Revenue Stamp

..fICh~1
it ";{m ~

FOR THE USE OF COMMISSIONER'S (OFFICE)

~'fJTl:f~.

9~24l{

-;:jR~11<IT

Fact of settlement noted in Form

NO.9and Form No. 24

31.l:T.

R~.31.

Entered in withdrawal Register

Clerk

8.8.

AAO

R'q.f.t.31T.
APFC

BmfT;i./:m.>T.

A/c.No.API
it "&)"q
m

"ffim-gq/A.G.--------------

Under Rs. .............................................

-q;ft~/~

MO/Cheques

1Jfu~2t

Amount authorised Rs.

~
2,

'"''''''''''''''''''''''

(Rupees. .,... """"'"''''

...
"""""""'"

...........

;.

'f.'ftm ~
M.0. Commission..

3.

:p1(lRr.8~ cwfi~

.................

1Jfu

Net Amount Payable'Rs.

4.

"""""'"''

~B.
ScrollNo.

'IJ.If.R
P.I. No.

..~
Date:

~.fR./P.C.

~.-R.31.

{I~s ~~.~

..........

/~.~.f.:t,an, / AAO/APFt

~.~}!ili~~,

(FOR USE INCASH'SECTION)

oo~

(~) @T(f[B.1

Paid by inclusion in.Cheque

No.;""""">;"''''''''..'''''''''''''''''''''''''''''''''','''''''''''''';'

@;;j,i<h

LPate

vide cash Book (Bank) Account No.1 Debit item No.

;:rrq~

'ff.rn.
D.A.

~B

@ojiCh

3{;q,
S.S.

if~'[TU

~~l'":f[.

~i~.f.t.an, / &t:3n,
A.P.F.C./

R.P.F.C.

...,

90~
~~~

~o:

10-~

~-ri.

1a-m (~.tfi.~)

"UJSerial No.

CQ~~)

~O'"$eJ~ 6~~Ko
;J~~o
ct>1~1~~n<1~it~
For Office Use only

Form No. 10-C (E.RS.)

Z1~oS~
~O~$ / ~

~~~6J~
~

iI

~/

Inward No.

~OW~ ~~~O,
199~
q~IGI~,
1995

BMPWYEES' PENSION SCUEME, 1995

Ji.~~o~6ro ~~~~
~~('.)J!~~o
L~~ ~~PJ. ~o&~~~o.
Ji.c;;S!J~eJ
~o-6~
~~o. 1995 t:S16~~!J~ Ji.~aue>o-6~ ~6fuJ.
Ch4-q1.[\~~,

1995~~mrHChIt11~

I~~~IUIY~~'~

~~CfiT~

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME, 1995

FO~ CLAIMING WITHDRAWAL BENEFIT I SCHEME CERTIFICATE

(~~~~~
,
(~~
1.

;6- ~1w ~O~

eFt~ -B~

oJ)

~r;5,JS;J

Cfi)

~~

a)

Name of the Member

eFt~~)I

QO~~(O

~i.sn)~~

i.sGSQ)OQ)

(Read the instructionsbefore filling up this form)

i,~ (;)eo~~O'"eJ~)

CfiT-;:rp:f

(in Block Letters)

w)

~~~~~;J(

eJ

) i,t;.:.

'@)~it-;:rp:f
b)

2 (a) ~~~ja

/~~l

crJ

[=rJ

Name of Claimant(s)
Date of Birth

c?~~

I Days

~eJ

/ Month

c=o=rJ
~o~~bo/

Year

.~.

(b) Marital Status

3.

oJ)

i$o~ ~~/r;5E, ~~

f'Rrr CfiT1111 / crfu

Cf)

a)

4.

Father's Name

~~730.
CfiTs

(;J~o.J~S)

OI1T1111 (~

/ Husband's

(VWl"8)

Name (if applicable)

~O~~~u-~73o:

~o~ ~w 730, ~~u-~

B&n wn-#mnB&n

Estt.

E/

. Code No. & Account NQ,

5.

~r;5,J$~ .J~oiJoO{\O~;J"3i.J~~o~ i,~,

f~

CfiT -;:rp:f <Of11m

BiWT

..

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it Cfi1<ffif
it I

..--.----------------.-

Name & Address of the

Establishment in which,
the merr:"'''r was last employed.

~o / -#mnBr.9<1T,
~~CfiTCfit?

Code No., Alc No.

!~a). 3e~~E>

ctIT

mm

Date of Joining

;60~OS;6~$~,so
~oa~ ~a /Rfu-q~

6.

ctIT

mm:.

Dateof membershipjoining the Fund

6(a) ;65,s;6J~oQ, ~S'~f\~o~~

~~MO ~e~
~S'~f\~ ~a :
ctIT mm
.
Reasonfor leavingservice & Date at leaving

itcrr~;r
7.

q)f CfiWJT(1m

~ ;r

~~~ .:;)W~~ (:)Q, ~~~~OS)

STCOq)f

1R!T

(~31&ro ii)
Full Postal address
(In Block Letters)

~/~~/~~e
m/sftmft/~
(ShrilSmtlKum)

~~w~/~~/~~

~/~/~

~5 ~~ ~o./ftR/PIN :

Slo, Wlo, 0/0

8.

~~;60~tiM

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eJ~

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>rqlU1'Bf
~ mmt

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mmt~
~

~ ~

9.

-qfufT(if;

fcr<Rur (cffir <IT'f(';f'r (1m

.~

Withdrawal Benefit

Are you willing to accept withdrawal benefit

OR Scheme Certificate
(Put a tick (v"') in the concerned box)
~~O&) ;)~~~
t'<fJ"{jd~~ ~e~
~~w, ~~~

~~~o ~~~~o
Scheme Certificate

D
t~)

~~)

Particulars of Family (Spouse & Children & Nominee)

'::>~i?&

~~;::)sa
~ fctfu
Date of Birth

~~ l;:wr I Name

-"
oJ) ~:x,'b

{)

~W02J.

/~

l'ie:> '::>02J0,;50

~
it B<siq
Relationship
with member

I Nominee

~~S<W

q; ) <rftcm:BGflI

. a)

Family Members

..

,
2

~~~ '::>oo~~ ~
.J1"f1~ct>if; m:~
q)f ;rrq
Name of the
guardian of Minor

o. ~Q..).;)~~~:?~ ~~o.> ~~~ ~oa 58 ~~o-~;S~

'o-~~ ~~~~~
~t!~~
58~ ctT~ c);~ -en~ 'en)~ fuRnm:<fC6t~~ -en':
Incase of death of member afterattainingthe age of,58 years~without
filingthe claim:

:':::;5"$~~(;jcl o,:).~
~o / ~

t~O"~::J(

~ol8S~J5' :

ct1~ ct1f'afu/ Dateof deathof the member:

<:)t~/~~"S<:)~ X<:)~oZJot;Jr:/
~c);~

I i'fi.tT~~~m

Name of the Claimants(s) i and relationship willithe members:

CJ

1. 3go~o :)'7~o (~~ ~O~ :.x3~ ~ ~~~ W~lr '( tf) r~~~~o~.
~CfiT~T
(mc;qc); ~~~c);
31PTR-Cfi~)
MODE OF REMITTANCE(PUTA TICK ( tf) INTHE BOr<AGAINSTTHE ONEOPTED)
;)

~o. 7;:) UO'dO@o~ '1,)~ ,:)~.;J"~~.;J" ~~o~

u;yO ~;:). E:;:Jg~O"jO".
~ 7 c);31Pt~ ~ "R~ ~ 'ij1:1TR
tYf-q;fi~<~"&m :

Cfi)

11G

a)

By postal money order at my cost the addressgivenagainstitem No,7

D)

~~$o.> ~$O!;N~~ ~:)o~ ~$O~ e.:is'lrW,j~O~,) ~~~~$

.;J"!;N<J~M~~~
"~S"lrW,j ~Wo.)3~lr;$J" ~o~~.

\9)

~~Cfi\it~~~t~~~WOT~6rffiC);

b)

~~<fi)~~~~~
Account payee chequesent directfor creditto my SB Alc (ScheduleBank)
Under intimationto me.

.:J5.D.e.;s"lrWJ~OW~.
~~

~I

~$O!;N

(~~ c':)~O"o~)

<fiT~

(~'

S.B,AccountNo.

~~~)

Name of the Bank (in block letters)

oi1"~
~~ (:)~ e"~O"o~)

mm / Branch

(in block letters)

lr ~~ :>~.;J"~

.~~ ~~

~CfiTWlqm
(~
~1ffiT~)
Full Address of the Branch
c)

~6 ~~osoK ;;J~c1P
00$00~ t:>oKJ 2J"~~

qiR~

B-q{~

Jo~~

~~

~ ~~ct>~If.tct>
IDD~

Bv ElectronicCredit in my S.B.Account throughCore BankingSystem,

12~~''1~J~, 1995 @oc.':S
~~ ~~
C,:)Wo.)~
~;5O"o.>~w~o~.
~:mq~~~,
c);~~~\%~

~o~JO"

1995
I

Are you availing pension under EPF 95 ?

31Trc~m~

<fi{

If so, indica1e :

~2... ~o./ifi.ifi.31T. ~/PPO

;);50 ~Ow

~~ ~i->~6:)6~

No.

~O jM~~~<5/~

~~ ~~~

"-

IDtt

By whom !ssued

~~e.> 'd86~~
(j) "-

~"'IUI@ ~~~'fcn~~~

I~:>~OO~~{~.ok

l:

\lf1-1~I{\ ~

~~~,

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY K~OWLEDGE

a<5~

/D~te:

~oU!fQaO"~~S';)!$.~fS:J;:)
J~~ 3t) 5"~ ~~ ~~
/~$~~-qy~m~~~C6Tf.mR

(;;)

Signature or Left.Hand Thumb impression of the Member I Claimants(s)

1YJ'C3iI~'LiiJilOqg'tf.e~
~.-;)
eJ
.

"

~~ft~

I ADVANCE"STAMPEDRECEIPT

(~;;) ~e5~;;) (,';)) e90~O :J~dS.)o~

if 1ft)1'Pffi~

~~~

i}e?dS.>~dS.>~e>~
~t))o~) / {-:S4(1ttO
(~) ctGm

) / (To be furnished only in case of (b) above)

~~ ~oZ)ot;J~;5 ~o~ ~o~ ~S'lr~ ~WelaOW~c\i)oef ~:>o~ 2J'$O~ ~S'lr~ef

~ob~ i;5~;Jt;J~:>Jo~/ ~e-bMS"'~$~c\i)O 9~~ ~t;JS"'c~oc~
(b.Y~o'5Jw

~.~~~6'

~'-_.

c;J.~w.; 3M'?0 ~.s~

,..--------

) ~.s~C~~<5.

'

(itcrct

it <i>RUT
m~

wr)~

~f.Ifu

/ ~ ~~it

mntt~wu~~f.@nmitit

f.t1R:~

~ @it ihmr it ~ 1)meaf<8n I

Received a sum of Rs.

( Rupees

only from Regional Provident Fund Commisioner / Officer-in-charge 01Sub-Regional Office

by deposit in my savings Bank Nc towards the settlement of my Pension Fund Account.

~ObM i;5:>~;)t;J
~~~bJ

(W~citwrBt~W

/ e.s~bJ9~>7~~ o~~ ~b;J ~.~~.

ftm~~f.Ifu~

/~~IDU~~)

(The space should be left blankwhich shall be filled by Regional Pravdent Fund Commissioner / Officer-in-charge).
~o~2 ~i;5~~;)~b~~o
e~. ')~~3&
QCfi'Z':rn1<;B! it ~1!3{<n qpt~it

~~;:S

~~~~.

'

CfiTf.mR
Signatureor LeftHandThumb Impressionof the memberon the stamp,

~i;5J~~ O~o'5J~u~;:S;)~~w'o'5JO"~;:S~;) ~Cc\i)J ;J"~~~o6"

WfliUm fcri<n "ITill

~ fcn ~

Certified that the particulars

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RS.1/-

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Stamp

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of the member given are correct and the member has signed I thumb impressed

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The details of wages and period of non-cont~ibutoiy

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before me.

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service of the member are as under:

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(18lf 3 Cfi/ 7 (t<ft.~.)~~CfiT~t
(Form 3 A / 7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund Office)
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Wages as on the date of exit I leaving

]5-]]-95CfiT~
(l@ ~ + ~~~)
(WR"Rf1Lm)
Wages (Basic + DA) as on 15-11-95 (if applicable)

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D.O.J. to 15-11-1995

Period of Non-contributory Service (Breaks in Service)

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Year / Month

16-11-1995 to D.O.L.

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5" ~~~o~~ R;fLcfr<ci~IL No. ()f Days

Particulars of Breaks month-wise should be furnished in
a separate statement Le. From Date of Joining to
15-11-1995 & 16-11-1995 to Date of Leaving Service.

4.

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Signature of Employer I Authorised Official
of th~ Estt.with Seal & Date

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(FOR THE USE OF COMMISSIONER'S OFFICE)

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M O. Commissioner

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towards withdrawal benefit.

net amount to be paid by M.a.

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PI No.

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Date:

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