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SUPPLIED FREE OF COST

# 4A FORM \,,
T

tnward No.

ffi EMPLOYEES'

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PROVIDENT FUND SCHEME ,1952

1.

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Name of the Member (in Block Letters)

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Father's Name : Husband's Name :(in case of married

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Name and Address of the Factory / Establishment in which the member was last employed

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4. srod doad, qp61*.eqr {irqr code No.Account

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+{r Bis; or*frttq' f oateof Leaving 6. dedo$$, Edc) 6Ddro

5. ddo$dr, E[,3 odDoE

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Service

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Full PostalAddress (in block letters)

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I ,uQgN{ 6oo]ffi i.--1,----*: q v ern4l put a'tick, in the box against

the one opted

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er) dd*de $?JFdg a$0o3DdFc,"E,ae; (do. 2,000/- ddnd aadrlpri dnd) er) wvfi 0'q{ q-{r+{r ertr(+-{m uodorr* A) by Postal Money Order at my cost (payabte upto

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to the address given in item No. 7

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e:) diJri nroa3d *nug dedemR ddq erD9soo$ s.todoa" a:odd (ud:B"oe3d eodoar/eoa3, depeO) dro ddoS:ddd ddE 233- d).rJod zjao *Jeac)r mbo- 6?.36 ab)-orid J,leoo$$, ei r$ne8 e-dn&6^S. ql) o* r Aqtr *riT -rc+ cqa Eo urm'iwqR-o *+/ero qi) fr qqr st{+ * ftq srfiT. Tzc ttfrd frcr

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byAcCount Payee Cheque sent direct for credit to my SBA/c (any Scheduled BanklPost Otfice/Co-operative Bank) under

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intimation to me (Advance stamped receipt furnished below)

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Branch........
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affe ny I{EFT Payment to rny B AJc. through Core Banking $ystern a-tl ffu'qEiR d- :Tt s.f. rqrff * ffiq. Mandatory : Please enclose attested oopy of first page of pass Book I CancBlied MICR cheque teaf
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Note ; Please enclose xerox copy of flrst page of S.B. A/c. pass book duly attested by employer for ensurlng the cheque reaches to the correct party. tloqdd,re-3ffiF 3-n dsadle,rte:,ilqrm i{q d?F' xwl- fq rydflt'd Fonm 3A for the current year sent/enclosed. J! aad e*e6o fJad>d qnr G'etq ff ql sisrq]-d Contribution for the current financlal year iqr?dri e{'SfdT;l g _c t(a3 c c Contribution
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FORM NO.s
Name of the Emolovee (in Block [etters

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

date of ioinino the Estt. in 6ase 6f olc

No. and oarticulars of orevious emolover. anv (if sb whether, h'e id a inerirber

FORM NO.{O

Father name (or Husband's Name in case of married wom

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.(information be furnished by the Employer if the Claim Form is Attested by the Employer) Certified that the above contributions have been included in the regular monthly remittances. qfrft-d Gtm rTqr qrcTfiT fuqr qRT fr'Eq$ffi Br{ff{ ft1'ffi-d qrfufi +sut edrood dd* dlod dnGerood(S) d{e;g z"Soaod(d)

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The applicant has signed/thumb impressed before me

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xd{dd 5b /er6ao ue-:r!Uod$ drid .bod) {r{" 6T Rnffi{ / Erq sTqE'IE q- 3rT5l',6l!Signatune/LeftlRight Hand Thumb lmpression of the Member

Signature of Employer/Authorised Officialwth rubber stamp

Elsl Name

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PF A/c. frlo. KN

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Desiqnation & Seal

# dwr DFc!-ARATToN oF NoN-EMpLovMENT

Pddd ?ia,4OA oSnea3d 1952 de-:dt: 59 e,rdde)d$ (1) oooaaod (q) d)q s"0ddeCN (2) asauaoorl (?3)o:D tl6oc:q udrr{Sd:n ;5:oGfir{eroeid idl$$ sooi:d u{oxi:C cJca{Boeb ;:o{c$eJ i)dodd Odld"o"enar:arbeai ii.dg de;i arut. .rdd: Sorlq dodd 5:o&8d4d). * sdroJ:;3:, #.,T.ft. q}q+ 1es2*'SiE (1)+1 trrcr (fi.) sq u*#f (2) * *rrET ({) * ut'ed-E rTrrffT tc ET-m e* TRE s-ffr t ai, erf+Ifuzre fr qiEr at{ * tiw 6- *qr ffi ft siE fr--cdr Rqirrc ttt .rr *t q-&E-} * qrq er*Eq ym'a
q-cqr

Note: ln the case of submrssion of application for settlement under clause(e) of sub-paragraph iliand in clause {2)

of

Paragraph 69 of the EPF Scheme, 1952, ihe claim should be subrnitted after two rnonths from the date of leaving service provided the member continues to remain un-employed in an estt. to which the Act applies

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6,r ERrgTtrEf{ i qTE 6rsi 4r 3l"rldr 6Tq Signature/Left/Right Hand Thurnb lnnpression ofthe Member

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qfrq q r*e 7 asoooano3:e e"dRAd e8erj eorJAd daeg / ADVANCE STAMPED RECEIPT (dteeJ 8 (s) nod?iFdg dog z.dnna3edr) i,rffi 3qt"ffi 8ffi) qrTm 6.m t I (to be furnised onty in case of S(b) above) ReTAqftAqrittftTdqb *al?ritsrqnTwiirqrarifrffirq,Gqnr+fuqRE{ftfterT\Fi srrrtffiffit*o.................. (tqqrr. ........ .r.r.r. .......qTR ftqT)
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from the Regional Provident Fund CommissioneilOtticer-in-charge of Sub Regionat.Jiiii:,r .. Provident Fund

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Account.
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+ fid-d{ + s$+{r + ftq / FoR THE USE OF COMMTSSTONER'S OFFTCE - il5tF, *qr or iiisrd:t Tfe' A.rerur Gqr rm ft*lm qGft qi cq{ zr til ziizi; .Gfu frqr rrcr
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Account Settled in ParUFull entered in F.21N24t2l9 and Withdrawal Register

ftR-6 Clerk
Under Rs,...................

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M.O./Cheque..

Pl. No. 3i-{rilrr

Section.

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A/c No. KN

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emrdcr qEr (Brrrt So aty M.O. Commission if any..............

tr{rasr Hrtr +c ersft r*-r+ Net Amount to be paid by M.O........

Rt'rd
Date

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Accounts Officer/ApFC

frqs wgwr + sr+.r + frq / FoR usE rN GASH sEcroN tw g+ (+n) fur dqr 1 + ilr+ va eq. fr.frd........ .* *+ iiqr
qrtr Wrf,rt +

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paid by inclusion in cheque

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'....Date...........................vide cash Book (Bank) Account No. 1 debit

item No.

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REMARKs

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A.P.F.C/R.P.F.C.

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Acknowledgement Received on..

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