-: 1 :Regn. No.

____________________
Emp. ID. _____________________

EEmp.
FORM
19
(For Office use only)
GROUP NO:
Office:

EMPLOYEES PROVIDENT FUND SCHEME, 1952

Form to be used by a Major Member of the Employees Provident Funds Scheme, 1952 for claiming the
Employees Provident Funds 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
which the member was last employed
: ________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
____________________________________________________________________________________________________________
4. P.F. Account No.
: _________________________
____________________________________________________________________________________________________________
5. Date of leaving service (in DD/MM/YYYY format): ______/______/__________
____________________________________________________________________________________________________________
6. Reason for leaving Service
: RESIGNED
____________________________________________________________________________________________________________
7. Full Postal Address (In Block Letters)
Shri / Smt / Kumari _________________________________________________________________________________________
S/o. W/o. D/o.

_________________________________________________________________________________________

Residence Address ________________________________________________________________________________________

_________________________________________________________________________________________
Pin Code No.

_________________________________________________________________________________________

___________________________________________________________________________________________________________
8. MODE OF REMITTANCE
(A) By Postal Money Order at my cost
(B) By account payee cheque to be sent

: ( ) Put a tick in the box against the one opted.

: (
(

) to the address given against item no. 7

) S. B. Account No. _________________________________

direct to Bank for credit to my S.B.A/c.

(Schedule Bank/Co-op. Bank/P.O.)

Name of the Bank: ______________________________________

under intimation to me

Branch: ________________________________________________

(Advance stamped Receipt furnished below)

Full address of the branch: ______________________________

_________________________________________________________
_________________________________________________________
_________________________________________________________

-: 2 :-

Contribution for the current Financial Year

20. 20.
Month

Amount of
wages

________________________

Workers
Share
E.P.F.

Employers Share
EPF difference
between 10% or
12% & 8.1/3%
(if any)
4

PENSION FUND
Contribution
8.1/3%

Refund
of Adv.

No. of days/
period of noncontributing
service(if any)

4a

Remarks

April
May
June

(a) Date of

July

Leaving service :

August
September
October

(b) Reasons for

November

Leaving service :

December

RESIGNED

January
February
March
Total

Signature of Employer with official seal

FORM NO.5

Sr.
No

PF
Account
No.

Name of the member

Fathers/ Husbands
Name

Date of
Birth

Sex

Date of
joining the
Fund

Total period
of previous
service as
on the date
of joining
the Fund

Remark

FORM NO.10
Sr.
No

PF
Account
No.

Name of the member

Fathers/ Husbands Name

Date of Leaving

Reasons for
leaving service

Remark

RESIGNED

Signature of Employer with official seal

-: 3 :-

Information to be furnished by the Employer if the claim form is attested by the Employer
Certified that the above contribution have been included in the regular monthly remittances.

_________________________________________________________________________________________________
The Applicant has signed / thumb impressed before me

X
_________________________________________
Signature of the employer or authorised officer

______________________________________________
Signature or Left 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 applies for a continuous
period not less than 2months immediately preceding the date of my application for final withdrawal of my Provident Fund
money.

X
Date: __________________
__________________________________________________
Signature or Left hand thumb Impression of the member
________________________________________________________________________________________-_________
P.T.O.

-: 4 :ADVANCE STAMPED RECEIPT

(To be furnished only in the case of 8(b) above)
Received a sum of Rs. _________________ (Rupees ______________________________________________________
__________________ only) from Regional Provident Fund Commissioner / Officer in Charge of S.R.O.
________________________ by deposit in my Savings Bank Account towards the settlement of my Provident Fund
Account.
Affix Re. 1/Revenue
Stamp

Signature or Left hand thumb impression of the member

The space should be left blank which shall be
filled in by Regional Provident Fund Commissioner /
Officer in Charge of S.R.O.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------(For the use of Commissioner's Office)
A/c. settle in part / full entered in F.21 A & W/d Register /Form 3 (FPF) from 9 (Revised)

Clerk
Section Supervisor
-----------------------------------------------------------------------------------------------------------------------------------------------------------------(Under Rs. ________________________________________________________________________________________
P.I. No. _____________________ M.O. / Cheque __________________________ Account No. ____________________
Section _____________________
passed for Payment for
Rs. ____________________ ( In Words ) Rs. _____________________________________________________________
M.O. Commission (if any)
(Net amount to be paid by M.O.) _____________________________ Date: ________________

Asstt. Commissioner

_________________________________________________________________________________________________
(For Use in Cash Section)
Paid by inclusion in Cheque No. ___________________ dated ________________________ vide Cash Book (Bank)
Account No.01 Debit item No. ______________________

SS
HC.
A.C.
R.C.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------REMARKS

_________________________________________________________________________________________________

-: 1 :-

Employee No.: ___________

FORM 10C PENSION

Group No. __________________
At

__________________

Serial No. __________________

Inward No.__________________
For Office use only
EMPLOYEES PENSION SCHEME, 1995
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR
CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Read the instructions before filling up this form)
1.

a)

Name of the member :- _________________________________________________________________

(in Block Letters)

b)

Name of the claimant :- _________________________________________________________________

2.

Date of Birth
(in DD / MM / YYYY Format)

3.

a)

Father's Name

:- _________________________________________________________________

b)

Husband's Name

:- _________________________________________________________________

(if applicable)
4.

5.

Name & Address of the

:- _________________________________________________________________

Establishment in which

_________________________________________________________________

the member was last

_________________________________________________________________

employed

_________________________________________________________________

Code No. & Account No.

Region / SRO Code
Estt. Code No.

6.

Reason for leaving service &

A/c No.

________ _________________________________________________________

Date of leaving
(in DD / MM / YYYY format)
7.

Full Postal Address (in block letters)

Shri / Smt / Kumari

_________________________________________________________________

S/o., W/o., D/o.

_________________________________________________________________
_______________________________________Pin Code: _________________

Telephone no. with STD Code: ________________________________________________________________

-: 2 :-

8.

Are you willing to accept Scheme in lieu of withdrawal benefit

9.

Particulars of Family (Spouse, Children & Nominee)

Name

Yes

No

Relationship
Name of the Guardian of
with Member
Minor
________________________________________________________________________________________________
(a) Family

Date of Birth

________________________________________________________________________________

Members

________________________________________________________________________________
________________________________________________________________________________

(b)

Nominee

________________________________________________________________________________
________________________________________________________________________________

________________________________________________________________________________________________
10.

11.

In case of death of member after attaining the age of 58 years without filling the claim :(a)

Date of death of member: __________________

(b)

Name of the Claimant and relationship with the member: - _____________________

MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ONE OPTED)
(a)

By Postal money order at my cost to the address given against item No. 7

(b)

By Account payee cheque sent directly for credit to my S. B. A/c (Scheduled Bank)
under intimation to me.

S. B. Account No.

______________________________________________

Name of the Bank

______________________________________________

(in block letters)

______________________________________________

Branch

______________________________________________

(in block letters)

Full Address of the Branch

______________________________________________

(in block letters)

______________________________________________
______________________________________________

12.

Are your availing pension under EPS-95?

if so, indicate :

PPO No. ______________ By whom issued __________

_________________________________________________________________________________________________
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

X
Signature or Left hand thumb
Impression of the Member/claimant
Date : ____________________
P.T.O.

-: 3 :ADVANCE STAMPED RECEIPT

(To be furnished only in case of (B) above )

Received a sum of Rs. _____________________

(Rupees ________________________________________________

__________________________________ only ) from Regional Provident Fund Commissioner / Officer in - charge of

Sub - Regional Office ____________________________________________

by deposit in my saving Bank A/c. towards

the settlement of my Pension Fund Account.

(The space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer in Charge)

Affix Re. 1/Revenue

Stamp

Signature or Left hand thumb impression of the

member on the stamp
_________________________________________________________________________________________________
Certified that the particulars of the members given are correct and the member has signed / thumb impressed before me.
The details of wages and period of non-contributory service of the member are as under:- (Form 3A/7 (EPS) enclosed for
the period for which it was not sent to employees Provident Fund Office)
Wages (Basic + D.A.) as on 15.11.95 (if applicable)

Wages as on the date of exit

Period of non contributory service
Year ______ Month _________ Days ________
Date: ________________
Signature of the Employer /
Authorized Official
_________________________________________________________________________________________________
P.T.O.

-: 4 :(FOR THE USE OF COMMISSIONER'S OFFICE)

(Under Rs. ___________________________________ P. I. No. ____________________________________________

M.O. / Cheque ____________________________________________________________________________________
Passed for payment for Rs. _________________ (in words _______________________________________________)
M. O. Commission (if any) ________________________ net amount to be paid by M. O. ________________________
towards withdrawal benefit.

C.C.

S.S.

A.A.O.

_________________________________________________________________________________________________
(FOR USE IN CASH SECTION )
Paid by inclusion in cheque No. ______________________________ dt. __________________________ vide Cash Book
(Bank) Account No.10 Debit item No. __________________________________

S.S.
A.C. ( Cash )
_________________________________________________________________________________________________
For issue of Scheme Certificate input Date Sheet is enclosed

C.C.

S.S.

A.A.O.

A.P.F.C. ( A/Cs )

_________________________________________________________________________________________________
( FOR USE IN PENSION SECTION )
Scheme Certificate bearing the control No. _________________________ Issued on ________________________ and
entered in the Scheme Certificate Control Register.

C.C.

S.S.

A.A.O.

A.P.F.C. ( PENSION )

Employees Provident Fund Organisation,

ELECTRONIC CLEARING SERVICE (CREDIT CLEARING) MANDATE FROM INVESTORCUSTOMER OPTION TO RECEIVE PAYMENTS THROUGH CREDIT CLEARING MECHANISM
(TO BE SUBMITTED ALONG WITH FORM 19/20/31/10C)
1. MEMBERS NAME (CUSTOMERS NAME)

: ________________________________

2. PARTICULARS OF BANK ACCOUNT

A) BANK NAME

: ________________________________
:________________________________

B) BRANCH NAME

C) 9-DIGIT CODE NUMBER OF THE

BANK AND BRANCH APPEARING ON THE
BANK MICR CHEQUE ISSUED BY THE BANK : ________________________________

(PLEASE ATTACH A BLANK CANCELLED CHEQUE ISSUED BY YOUR BANK FOR VERIFYING THE
ACCURACY OF THE MICR CODE NUMBER. IF A SALARY A/C IS MENTIONED, PLEASE ENSURE THAT THE
A/C IS LIVE TILL AMOUNT IS CREDITED)
D) ACCOUNT TYPE
WITH CODE 10/11/13

SAVINGS BANK ACCOUNT

E) S.B. A/C NO. (AS APPEARING

ON THE CHEQUE BOOK)

:________________________________

F) IFSC (11-DIGIT) CODE, 

:________________________________

G) DATE OF EFFECT

:________________________________

I HEREBY DECLARE THAT THE PARTICULARS GIVEN ABOVE ARE CORRECT AND COMPLETE. IF THE
TRANSACTION IS DELAYED OR NOT EFFECTED AT ALL FOR REASONS OF INCOMPLETE OR INCORRECT
INFORMATION, I WOULD NOT HOLD THE USER INFORMATION RESPONSIBLE. I HAVE READ THE
OPTION LETTER AND AGREE TO DISCHARGE THE RESPONSIBILITY EXPECTED OF ME AS A
PARTICIPANT UNDER THE SCHEME.

DATE:

SIGNATURE OF THE CUSTOMER/MEMBER.

CERTIFICATE OF CUSTOMERS BANK (**)

CERTIFIED THAT THE PARTICULARS FURNISHED ABOVE ARE CORRECT AS PER OUR RECORDS.
BANK STAMP
DATE:

SIGNATURE OF THE AUTHORISED OFFICIAL OF THE BANK AND NAME

(**) Note: Certificate of the customers Bank is required only if the member is unable to enclose a bank cancelled cheque
of his SB A/c.