EMPLOYEES PROVIDENT FUND SCHEME,

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Daniella Jody Goodwin
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1 Regn. No FORM 19 (For Office use only) GROUP NO: OFFICE AT: EMPLOYEES PROVIDENT FUND SCHEME, 1952 Form to be used by a Major Member of the Employees Provident Scheme, 1952 for claiming the Employees Provident Fund Dues (Para 69) (Refer to the Instructions ) 1. Name of the member (In Block Letters) 2. Father s Name (or husband s name in case of married woman) 3. Name & Address of the Factory/Establishment in in which 4. P.F. Account 5. Date of Leaving service 6. Reason for leaving service Full Postal Address (In Block Letters) Shri./Smt./Kumari. S/o. W/o. D/o. Resident Address Pin Code 8. Mode of Remittance (A) By Postal Money order at my cost (B) By account Payee cheque to be sent direct to bank for credit to my S.B.A.A/c.. (Schedule Bank. P.O.) (Advance stamped Receipt furnished below) ( ) Put a tick in the box against the one opted. to the address given against item no.7 S.B.Account Name of the Bank Branch : Full address of the branch :

2 Contribution for the current Financial Year A/c. MH/ Employee s Share Worker s Share Refund of days / period Month Amount E.P.F. difference PENSION FUND of Adv of non-contributing Remarks of Wages E.P.F between 10% Contribution service (if any) & 81/3% (if any) 8 1/3% a 4b Apr 20 May June July (a) Date of leaving Service if any Aug Sep Oct Nov (b) Date of leaving Service if any Dec Jan 20 Feb Mar Total Signature of Employer with Official Seal

3 FORM 5 Sr. 1 A/C 2 Name of the employee (in Block letters) 3 Father Name (or husband s name in case of married woman) 4 Date Of Birth 5 Sex 6 Date of Joining the Fund Total period of previous Service as on the date of Joining the Fund (enclosed Scheme Certificate if Applicable) 8 Remarks 9 Signature of Employer or other authorised Officer and Stamp of the factory/establishment. Dated

4 Information to be furnished by the Employer if the claim Form is attested by the employer Certified that the above contribution has been included in the regular monthly remittances. The Applicant has signed thumb impressed before me Signature of the employer or authorised office Signature of Left/Right hand thumb impression of the member Dated : Designation & Seal : Encl : Declaration of non-employment I declare that I have not been employed in any factory / establishment to which the act applied for a continuous period not less than 2 months immediately preceding the date of my application for final withdrawal of my Provident Fund money. Date Signature of Left/Right hand thumb impression of the member

5 FORM 10 Sr. 1 A/c. 2 Name of the employee (in Block letters) 3 Father Name (of husband s name in case of married women) 4 Date of leaving Service 5 Reason for leaving Service 6 Remarks 7 Signature of Employer or other authorised Officer and Stamp of the factory/establishment Dated

6 Information to be furnished by the Employer if the claim Form is attested by the employer Certified that the above contribution has been included in the regular monthly remittances. The Applicant has signed thumb impressed before me Signature of the employer or authorised office Signature of Left/Right hand thumb impression of the member Dated : Designation & Seal : Encl : Declaration of non-employment I declare that I have not been employed in any factory / establishment to which the act applied for a continuous period not less than 2 months immediately preceding the date of my application for final withdrawal of my Provident Fund money Date Signature of Left / Right hand thumb impression of the member

7 ADVANCES STAMPED RECEIPT (to be furnished only in case of 8(b) above) Received a sum of Rs. (Rupees only) from Regional Provident Fund Commissioner by deposit in my savings Bank Account towards the settlement of my Family Pension Scheme Account. The space should be left blank which shall be Filled in by Regional Provident Fund Commissioner Signature or Left/Right Hand thumb impression of the member (For the use of Commissioner s Office) A/c. settle in part / Full entered in f.21 A & W/d Register / Form 3 (FPF) / Form 9 (Revised) Clerk Head Clerk (Under Rs. ) P.I. M.O./Cheque Account Section Passed for Payment for Rs. (in words) Rs. M.O. Commission (if any) (Net amount to be paid by M.O.) Date : Account Officer For Use in Cash Section Paid by inclusion in / Cheque dated vide Cash Book (Bank) Account 10 Debit Item H.C. A.C R.C. REMARKS

FORM 5(IF) THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME, (v) Code No. & Account No. in P.F. : RO/SRO Code Estt.

FORM 5(IF) THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME, 1976 ( To be filled up separately by each claimant. In case the claimant is minor it should be filled up by the Guardian on his/her behalf. Where