AssociateID

UAN
~

Aadhar No.

.q ~

~./Mobile

Number

~ fm)- / For Office use only

GTCIT~/Clam

I.D.

~~-f.'tfil"~.1952
EMPLOYEES' PROVINDENT FUND SCHEME. 1952
U"q"'jf-19/ Form -19
<!6 'IiT'f ~
f.'tfil"<PT GTCITq;ffl Wf!I ~
~
f.'tfil"~
~ ~
~
srn 'Iffi \ifJ11"
From to be used by major member of the Employees' Provident Fund Scheme, 1952 for claiming the
Provident Fund dues [Para72] (5)]
"!I'I"'lI ~
"ft l!@ ~
q;)- ~ I (Read the instructions before filing up this for
1.

4.

~
<PT 'fIif ~
31~. ~
Name of the member(in block letters).
~/tM <PT"'W! ~
~
~ 1fl"'ffi Ti}
Father's! husband's Name in the case of married
women
<PT "'W! er lfffi" IuffiI1 ~
~
iIR ~
~
lflIT I!If /Name and Address of
the Factory !Establishment in which the member
was last employed.
Wffi" ~./ Account No.

5.

qlt ~lDate

6.

<PT ~

7.

lP.i ~

2.

~!~

3.

ofleaving Service

/Reason

of leaving Service

<PT '!'T lfffi"

Full postal address (in block letters)

I---

~/~/~/

ShrilSmt.lKumari

W/~/~/

S/ofW/o/D/o

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

"T"fR qlt ~

8.

"i'itttffl flI;"m ~

/ Mode of Remittance

Put a 'Tick'

(ci ~

""*~

lR

srn/

~ /~)

Wffi" ~.(~

~ ~
-.hi; "~iIl;'1f.'1q> ~
>lvrr \ifJ11"/ (b) By account payees

Wffi" ~

"I 101> <'f1ll1i

<f

3ITGRIT

.q ~

1TI1tffllR

~.I

tq; Wffi"

tq; <PT"'W!/

cheque

To the address given against item No.7

S.B Account no .

Name of the Bank

electronic mode sent Direct for credit to my S.B. A/e

W<YT/

(Scheduled Bank/P.O.) Under intimation to me.

(<II1R W
1t; lmtt/~ __ 11ft" 'qlIj lIftt~

~.~.,*.m / IFS Code

um

1ft

wit

(3iIWf ~
~

<OntRT

it ~

\if"!

~/Date

\lIffiT ~ ~
ql't ~

I Date of Joining

Full Address of the Branch

"ffirG ~ eft ~~)

(Advance Stamped Receipt furnished below)
fcmur "ffift ~ / Certified that the particulars are true to the best of my knowledge.

the Establishment

..

Contribution for the current Financial Year (i'fIf 2012-13

atmR
Contribution

Month

il

lfffi" /

of Birth .

Tffi'! fcffli'flf <PT ~/

1fT"il

"'l"f ~

Branch

W<YT q;r ~

Please attach a copy of cancelled/blank Cheque)

in Box against the one opted

1lG ~. 7

q;ffl ~

(a) By Postal Money

Oder at my cost.
(~) ~

<Rtql" lR ~

Pin No./~

'Nf<i.

tt
Wa
ges

"""""
EMPLOYEE
'l!t
"'.'1.
f.!.

EPF

FP

~;m3Fl1U"1Ita.~

sr er

Period of Break ifany

March

April
~May
"l.'l June
~July
_~t

f.!.

EPF

'l.q.
FP

il

~,,:t~=~mm

atmR
Contribution

TOTAL

"'.'1.

'lill)(Not applicable from 2012-13)

'fi!RT
Month

f.1llllftIT

EMPLOYERS
'l.q.
"'.'1.
f.!.
FP
EPF

0!T'l

Wag
es

"""""
EMPLOYEE
'l.q.
"'.'1.
f.!.

FP

EM=ERS
"'.'I.to'!.
EPF

Period of Break ifany

'!j<I
TOTAL
'1.11.
"'.'I.f.!.
'l.q.
FP
EPF
FP

EPF

~September
~October
'IO"R
November
~December
~
January
q;ffi) FellrlJary

For Cognizant Technology Solutions India Pvt. Ltd.

(X)
#~
~ ~/Member's
Signature
Form 19 (www.epfindia.gov.in)

#~

Page lof2

~ ~

Employer's
Signature
!Employ's
Signature

Authorized Signatory

~Gf1IT"\TCI"'3I~am~1'iPln7["llftm~~~am~\iIl'1l")
(Information to be furnished by the Employer if the Claim Form is Attested by the Employer)
1'iPlni1ITffT 1$ ~
amGR f.I<lf'4o~
\Jfl'fT "1"1 -.lfu lj mfiffi
1/ Certified that the above contributions have been included in
the regular monthly remittances.

For Cognizant Technology Solutions India Pvt. Ltd.

f<l;s'/3Mor wrrm tiThe Applicant has signed/thumb impressed before me.

mff" ~ m<R ~

(X)
~

Signature of Employer
Authorized Signatory
.

if; ~/

if; ~

"iIlli/c;nt

if; ~

<liTf.mR

Signature or Left! Right hand thumb impression of the member

~lDate
~
<liT'IG-WI 3l'R ~
Designation & Seal of Employer
~/Encl.
~
l'f "::j ~ ~ tl't1IvIT / Declaration of non-employment
~
: Cfi."I'f.f.!I".~
1952 if; fm 69 if; ~-fm (2) if; ~
<) 3l'R ~-;ro (1) if; ~
I) if; 3R'I'fcr f.'It!cR if; ~ ~
~
if; ~
Ti Gf1IT~
~
~ ~
~ Gl ~
if; "iITG
~
CfiVIT ~
~
~
WlTIlR ~
W ID 3{ercrr~
~
Ti ~
ID Riffi lR ~
l'fl1j:, 'TIff t I
Note: In the case of submission ofapplication for settlement under clause (S) of sub-paragraph (i) and in clause (b) of Sub paragraph (2) of paragraph 69 of the
EPF Scheme, 1952 the claim should be submitted after two months from the date ofleaving service provided the member continues to remain un-employed
in an estt. to which the Act applies.

(X)

/Date

3{l':I<IT
"iIlli/c;nt

if; ~

if; ~

<liT f.mR

Signature or left! Right hand thumb impression of the member

3lftrq feq;c "Rlfi ~

(~

8<)

Ti ~

if; ~

\iIJlt)

ADVANCE STAMPED RECEIPT (To be furnished only in case of8(b) above)

Ml<i ~

~--Rm ~

~/wrnt

( ~

~
) ql) ~

Received a sum of ~
Commission/Officer-in-Charge

3ltR ~

Tff if; f.'It!cR

lR

3ltR ifi'.IO'fq; Tff 1) "SIT'<f

ql) I

(~

only) from Regional Provident Fund

by deposit in my Saving Bank account towards the settlement of my

of Sub Regional Office

Provident fund Account.

1.00 ~ <tit ~
~~\iIfIl

feq;c

The space should be left blank which shall be filled in by

Regional Provident Fund Commissioner, Office-in charge
of Sub-Regional Office.

Tff <liT f.\qcr;f

1'iPln 7["llfI '!>Jlf.=i. 21-"11/2

~
om ~

(X)

Affix 1.00 ~ Revenue

Stamp

~
if; ~
"lIT"UI:i/c;nt ~ if; atrr.B <liT f.mR
Si ature or LeftlRi t hand thumb im ression of the member
~/
(For the use of Commissioner's Office)
tr. it f.!I". JIInl 9 (mTrfmr) 1) ~
ql)

~/3

Nc. Settled in Part/Full Entered in F-21-N2 and with drawal Register! Form 3 (F.P.F.) Form 9(Revised)

wr.~"",.

3Pj.lIlf

SSA
~

if; ~/

SS
UnderRs

'!.fRlT'f lfG" .=i.

WCIT.=i.

P.I- No.

Account No.

Accounts Officer

Dated

~
Paid by cheque No
if; WCIT~-10

lfG"

ar:rwr it

m it ~)/

(FOR USE IN CASH SECTION)

Date.
am 1'iPln 7["llfI

'W! ~

Vide cash book

and Account No. ID Debit item No.

______

3Pj.lIlJ---.LSS

<1.31T./el.31TI A.C.IR.C.

~/REMARKS

Form 19 (www.epfindia.gov.in)

Page 2 of2

UAN

AssociateID
Aadhar No.

eksckby la-@ Mobile Number

dsoy dk;kZYk; ds iz;ksxkFkZ@ For Office Use Only
nkok la[;k@Clam I.D. .....................

fudklh ifjYkkHk@;kstuk izek.ki= ds nkos gsrq iz;ksx fd;k tkus okyk izi= 10 lh
FORM 10C FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
deZpkjh isa ku ;kstuk] 1995 EMPLOYEES PENSION SCHEME, 1995
izi= Hkjus ls igys funsZkksa dks i<s+a@(Read the instructions before filing up this form)
;fn lnL;rk 180 fnu xSj vaknk;h lsok dks NksM+ dj] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA WITHDRAWAL BENEFIT IS NOT ADMISSIBLE IF
MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRIBUTING PERIOD

1.

d lnL; dk uke LiV v{kjksa esa @ Name of the Member (In Block Letters): ____________________________________________
[k nkosnkj dk uke
Name of the claimant (s): ______________________________________________________________________________

2.

tUefrfFk@Date of Birth (dd/mm/yyyy)

firk dk uke /Fathers Name________________________________________________________________________________

3.

ifr dk uke Husbands Name (If applicable)___________________________________________________________________

LFkkiuk dk uke o irk ftlesa lnL; var esa fu;ksftr FkkA@
__________________________________________________________
Name & Address of the
Establishment in which, _______________________________________________________________________________
the member was last employed
dksM la- rFkk [kkrk la{ks=@ dk dksM
LFkkiuk dh dksM la[kkrk laCode No. & Account No.
Region/Off Code
Estt. Code No.
A/c No.

4.

5.

31309

dk;kZjaHk frfFk@Date of Joining the Estt. ___________________________________________________________________

lsok NksM+us dk dkj.k rFkk
RESIGNED
lsok NksM+us dh frfFk
____________________________________________________________________________
Reason for leaving service &
Date of Leaving
___________________________________________________________________________
iwjk irk LiV v{kjksa esa
Full Address (In Block Letters) ________________________________________________________________________

5A)
6.

7.

Jh@Jherh@dqekjh@Sh. /Smt. /Km. _______________________________________________________________________

iq=@iRuh@iq=h@S/o, W/o, D/o._________________________________irk@Adress _______________________________
______________________________________________________________________ fiu/PIN _____________________

For Cognizant Technology Solutions India Pvt. Ltd.

(X)
# lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fukku
Signature or Left / Right hand thumb impression of the member

Form 10C (www.epfindia.gov.in )

# fu;ksDrk ds gLrk{kj /Employers Signature

Authorized Signatory

Page 1 of 4

8.

D;k vki fudklh ifjYkkHk ds LFkku ij ;kstuk

gkWa Yes
ugha No
izek.ki= Lohdkj djus ds fy, rS;kj gSaA
Are you willing to accept Scheme Certificate
in lieu of withdrawal benefits
;fn lnL;rk 180 fnu xSj vaknk;h lsok dks NksM+ dj] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA
Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service.

9.

ifjokj dk fooj.k ifr@iRuh rFkk cPps rFkk ukfefr

Particulars of Family (Spouse & Children & Nominee)
(flQZ ;kstuk izek.k i= ds fodYi ds fy,@applicable only for Scheme Certificate option)
uke
tUe frfFk
lnL; ds lkFk laca/k
ukckfyd ds vfoHkkod dk uke
Name
Date of Birth
Relationship with Member
Name of the guardian of minor
ifjokj ds lnL;
Family members

d
(a)

[k
(b)
10.
d
[k
11.
d
[k

ukfefr
Nomine
fcuk nkok fn, 58 okZ dh vk;q izkIr djus ds ckn lnL; dh e`R;q gksus ij] %&
In case of death of members after attaining the age of 58 years without filling the claim:lnL; dh e`R;q dh frfFk@Date of death of the member
nkosnkjks ds uke@rFkk lnL; ls mldk laca/k@Name of the Claminant(s)/and relationship with the member
/kuizsk.k dk ek/;e fodfYir fof/k ds vuqlkj lacaf/kr dksVd esa fVd djsa
Mode of remittance (put a tick in the box against the one opted)
en la- 7 esa fn, irs ij esjh ykxr ij Mkd euhvkMZj }kjk
By postal money order at my cost to the address given against item No.7:
eq>s lwfpr djrs gq, esjs cpr [kkrk la-vuqlfw pr cSad@Mkd?kj esa js[kfdar psd@ bysDVkWfud ek/;e ls vknkrk [kkrk lh/ks Hkstk tk,@ (b) By account
payees cheque/ electronic mode sent Directly for credit to my S.B. A/C (Scheduled Bank /P.O.) under intimation to me.
cpr CkSad [kkrk la+@aS.B. Account No.

cSad dk uke LiV v{kjksa esa@Name of the Bank (In Block Letters) :

________________________________
________________________________

kk[kk LiV v{kjksa esa @Branch (In Block Letters)

:
________________________________
vkbZ-,Q-,l-- dksM@ IFS Code
: ________________________________
kk[kk dk iwjk irk LiV v{kjksa esa /Full address of the Branch (In Block Letters) :
_______________________
(vius cSad [kkrs ds [kkyh@j pSd dh ,d izfr layXu djsa Please attach a copy of cancelled/blank Cheque)
______________________________________________________________________________________
12.

D;k vki d-is-a ;ks- 95 ds rgr isa ku izkIr dj jgsa gSa \

Are you availing pension under EPS-95 \
;fn gkWa] rks bafxr djsa
If yes, indicate

ih-ih-vks- laPPO No.

gka@Yes

ugha@No

fdlds }kjk tkjh

By whom issued..

izekf.kr fd;k tkrk gS fd fooj.k esja s vf/kdre Kku ds vuqlkj lR; gS@
a Certified that the particulars are true to the best of my knowledge
(X)
fnukad
Date .......................

lnL;@nkosnkj ds gLrk{kj vFkok ck,a gkFk ds vWaxwBs dk fukku

Signature or left Hand Thumb impression of the Member/Claimant
For Cognizant Technology Solutions India Pvt. Ltd.

# fu;ksDrk ds gLrk{kj /Employers Signature

Form 10C (www.epfindia.gov.in )

Authorized Signatory

Page 2 of 4

vfxze izkfIr jlhn

Advance Stamped Receipt
dsoy ij [k ds ekeys esa gh izLrqr fd;k tk,
[To be furnished only in case of (b) above]
isa ku fuf/k [kkrs ds fuiVku Lo:i {ks=h; Hkfo; fuf/k vk;qDr@mi&{ks=h; dk;kZy; ds izHkkjh vf/kdkjh ls vius cpr cSad [kkrs esa tek }kjk
----------------------------------------- kCnksa esa -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- dh jkfk izkIr dhA
Received a sum of ........................................ (Rupees.................................................................................) only from
Regional Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office........................by deposit in my
savings Bank A/c towards the settlement of my Pension Fund Account.
ck;h rjQ fn, fjDr LFkku dks {ks=h; Hkfo; fuf/k vk;qDr@izHkkjh vf/kdkjh }kjk Hkjk tk,xkA
The space should be left blank which shall be filled by Regional Provident Fund
Commissioner/Officer-in-charge)
1 jktLo fVdV

(X)

fVdV ij lnL; ds gLrk{kj vkSj ck; gkFk ds vaxwBs dk fukku

Signature & left hand thumb impression of the member on the stamp

1 Revenue
Stamp

izEkkf.kr fd;k tkrk gS fd lnL; }kjk fn, fooj.k lgh gS vkSj lnL; us esjs le{k gLrk{kj fd, gSa@vaxwBk fukkuh yxkbZ gSA
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.
lnL; dh etnwjh ,oa xSj vaknk;h lsokof/k ds fooj.k fuEukuqlkj gSa %&
The details of wages and period of non-contributory service of the member are as under:
izi=&3,@7 d-is-a ;ks- ml vof/k dk layXu gS ftl vof/k gsrq ;s deZpkjh Hkfo; fuf/k dk;kZy; dks Hksts ugha x, FksA
(Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employees Provident Fund Office)
fnukad 15-11-95 dks etnwjh ewy osru + egaxkbZ Hkkk ;fn ykxw gS
Wages (Basic +D.A.) as on 15.11.95 (if applicable)
lsok R;kxus dh frfFk dks etnwjh
Wages as on the date of exit

xSj vknk;h lsok dh vof/k %

Period of non contributory Service :
okZ@ekg
Year/Month

fnu
No. of days

fnukad
Date ..........................

NIL

For Cognizant Technology Solutions India Pvt. Ltd.

fu;ksDrk@izkf/kd`r vf/kdkjh ds gLrk{kj

Signature of Employer/Authorised Official
Authorized Signatory

vk;qDr dk;kZy; ds iz;ksxkFkZ (For the use of commissioners office)

---------------------------------------------------------------------------------------------------- ds v/khu@vnk;xh en la- ---------------------------------------------------------------------------------------------------------- euhvkMZj@psd
Under .................................................................P.I.No.................................................................... M.O./Cheque.
--------------------------------------------------------- kCnksa esa ----------------------------------------------------------------------------------------------------------------------------- ------------------------- dh vnk;xh gsrq Lohd`r fd;kA
Passed for payment for .......................... (in words) ..................................................................................................
euhvkMZj dehku ;fn dksbZ gS ------------------------------------------------------------------------------------------- fudklh ifjYkkHk dh fuoy jkfk ----------------------------------------------------------------------------M.O.Commission (if any) ....................................... net amount to be paid by M.O ............................ towards withdrawal
benefit.

lk-lq-lSSA

Form 10C (www.epfindia.gov.in )

vuqi;Zos{kd
S.S.

l-ys-vf/kA.AO.

Page 3 of 4

udnkuqHkkx ds iz;ksxkFkZ
(For use in Cash Section)
psd la- ----------------------------------------------------------------------------------------------------------------------------- --------------- fnukad --------------------------------------- }kjk lans; ftls udn iqfLrdk cSad [kkrk
la-&10 MSfcV en la- --------------------------------------------------------------------- ij ntZ dj fy;k gSA
Paid by inclusion in cheque No.............................. Dt ............................vide Cash Book (Bank) Account No.10 Debt
item No...............................................................

vuq i;ZS.S

l- vf/k- udn
AC (Cash)

,l- ,l- - tkjh djus ds fy, vkbZ- Mh- ,l layXu gS %&

For issue of S.C., IDS is enclosed

lk-lq-l-

vuq- i;ZS.S.

SSA.

l-ys-vkA.AO.

l-Hk-fu-vk- ys[kk
APFC (A/cs.)

isa ku vuqHkkx ds iz;ksxkFkZ

(For use in Pension Section)
;kstuk izke.ki= ftl ij fu;a=.k la- ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- mfYyf[kr gS] dks fnukad -------------------------------------------------------------------------------- dks tkjh fd;k vkSj bldh izfofV ;kstuk izek.ki= fu;a=.k iath esa dhA
Scheme Certificate bearing the control No .....................................issued on ....................................................and
entered in the Scheme Certificate Control Register.

lk-lq-l-SSA

vuq- i;ZS.S.

Form 10C (www.epfindia.gov.in )

l-ys-vkA.AO.

l-Hk-fu-vk- ys[kk
APFC (A/cs.)

Page 4 of 4

"FORM NO. 15G

[See section 197A(1), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A(1A) of the Income-tax Act, 1961 to be made by an individual or a person (not being a company or rm) claiming
certain receipts without deduction of tax.
PART I
2. PAN of the Assessee
1. Name of Assessee (Declarant)
3. Assessment Year
( for which declaration is being made)
4. Flat/Door/Block No.

5. Name of Premises

8. Road/Street/Lane

9. Area/Locality

11. Town/City/District

12. State

6. #Status
7. Assessed in which Ward/Circle
10. AO Code(under whom assessed last
time)
Area Code AO Type Range Code

13. PIN
15. Email

AO No.

14. Last Assessment Year in which

assessed
17. Present Ward/Circle
18. Residential Status ( within the
meaning of Section 6 of the Income Tax
Act,1961)
20. Present AO Code (if not same as
above)

16. Telephone No. (with STD Code) and Mobile No.

19. Name of Business/Occupation

21. Jurisdictional Chief Commissioner of Income-tax or Commissioner of Income-tax (if not assessed to
Income-tax earlier)
22. Estimated total income from the sources mentioned below:

Area Code AO Type Range Code

AO No.

(Please tick the relevant box)

Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income form units referred to in Schedule IV
The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to in ScheduleV
23. Estimated total income of the previous year in which income mentioned in Column 22 is to be included
24. Details of investments in respect of which the declaration is being made:
SCHEDULE-I
(Details of shares, which stand in the name of the declarant and benecially owned by him)
No. of
Class of shares &
Total value
Distinctive numbers of the shares
shares
face value of each
Date(s) on which the shares were acquired by the
of shares
share
declarant(dd/mm/yyyy)

Description of
securities

SCHEDULE-II
(Details of the securities held in the name of declarant and benecially owned by him)
Date(s) of
Date(s) on which the securities were
Number of securities
securities
Amount of securities
acquired by the declarant(dd/mm/yyyy)
(dd/mm/yyyy)

SCHEDULE-III
(Details of the sums given by the declarant on interest)
Name and address of the
person to whom the sums are
given on interest

Amount of
sums given
on interest

Date on which the sums were given on

interest(dd/mm/yyyy)

Period for which sums were

given on interest

Rate of
interest

SCHEDULE-IV
(Details of the mutual fund units held in the name of declarant and benecially owned by him)
Name and address of the
Income in respect of
Number of Class of units and face value of each
Distinctive number of units
mutual fund
unit
units
units

SCHEDULE-V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Oce where the account under the National Savings Scheme
is maintained and the account number

Date on which the account

was opened(dd/mm/yyyy)

The amount of
withdrawal from the
account

.
**Signature of the Declarant
Declaration/Verication

*I/Wedo hereby declare that to the best of *my/our knowledge and belief what is stated above is correct, complete and is truly stated. *I/We
declare that the incomes referred to in this form are not includible in the total income of any other person u/s 60 to 64 of the Income-tax Act, 1961. *I/We further,
declare that the tax *on my/our estimated total income, including *income/incomes referred to in Column 22 above, computed in accordance with the provisions
of the Income-tax Act, 1961, for the previous year ending on .................... relevant to the assessment year ..................will be nil. *I/We also, declare that *my/our
*income/incomes referred to in Column 22 for the previous year ending on .................... relevant to the assessment year .................. will not exceed the maximum
amount which is not chargeable to income-tax.
Place:
Date:

.
Signature of the Declarant

..
..

PART II
[For use by the person to whom the declaration is furnished]
2. PAN of the person indicated in Column 1 of Part II
1. Name of the person responsible for paying the income referred to in Column 22 of Part I
3. Complete Address
4. TAN of the person indicated in Column 1 of Part II
5. Email

6. Telephone No. (with STD Code) and Mobile No.

8. Date on which Declaration is Furnished

(dd/mm/yyyy)

9. Period in respect of which the dividend has been

declared or the income has been paid/credited

12. Date of declaration, distribution or payment of dividend/withdrawal under the

National Savings Scheme(dd/mm/yyyy)

7. Status
10. Amount of income paid

11. Date on which the income

has been paid/
credited(dd/mm/yyyy)

13. Account Number of National Saving Scheme from which withdrawal has
been made

Forwarded to the Chief Commissioner or Commissioner of Income-tax

Place:
Date:

..
.

Signature of the person responsible for

paying the income referred to in
Column 22 of Part I

Notes:
1.
2.
3.
4.
5.

The declaration should be furnished in duplicate.

*Delete whichever is not applicable.
#

Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a rm) under section 197A(1A).
**Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
Before signing the declaration/verication , the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all
respects. Any person making a false statement in the declaration shall be liable to prosecution under 277 of the Income-tax Act, 1961 and on conviction be
punishablei) In a case where tax sought to be evaded exceeds twenty-ve lakh rupees, with rigorous imprisonment which shall not be less than 6 months but which
may extend to seven years and with ne;
ii) In any other case, with rigorous imprisonment which shall not be less than 3 months but which may extend to two years and with ne.

6.

The person responsible for paying the income referred to in column 22 of Part I shall not accept the declaration where the amount of income of the nature referred
to in sub-section (1) or sub-section (1A) of section 197A or the aggregate of the amounts of such income credited or paid or likely to be credited or paid during the
previous year in which such income is to be included exceeds the maximum amount which is not chargeable to tax.";

"FORM NO. 15G

[See section 197A(1), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A(1A) of the Income-tax Act, 1961 to be made by an individual or a person (not being a company or rm) claiming
certain receipts without deduction of tax.
PART I
2. PAN of the Assessee
1. Name of Assessee (Declarant)
3. Assessment Year
( for which declaration is being made)
4. Flat/Door/Block No.

5. Name of Premises

8. Road/Street/Lane

9. Area/Locality

11. Town/City/District

12. State

6. #Status
7. Assessed in which Ward/Circle
10. AO Code(under whom assessed last
time)
Area Code AO Type Range Code

13. PIN
15. Email

AO No.

14. Last Assessment Year in which

assessed
17. Present Ward/Circle
18. Residential Status ( within the
meaning of Section 6 of the Income Tax
Act,1961)
20. Present AO Code (if not same as
above)

16. Telephone No. (with STD Code) and Mobile No.

19. Name of Business/Occupation

21. Jurisdictional Chief Commissioner of Income-tax or Commissioner of Income-tax (if not assessed to
Income-tax earlier)
22. Estimated total income from the sources mentioned below:

Area Code AO Type Range Code

AO No.

(Please tick the relevant box)

Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income form units referred to in Schedule IV
The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to in ScheduleV
23. Estimated total income of the previous year in which income mentioned in Column 22 is to be included
24. Details of investments in respect of which the declaration is being made:
SCHEDULE-I
(Details of shares, which stand in the name of the declarant and benecially owned by him)
No. of
Class of shares &
Total value
Distinctive numbers of the shares
shares
face value of each
Date(s) on which the shares were acquired by the
of shares
share
declarant(dd/mm/yyyy)

Description of
securities

SCHEDULE-II
(Details of the securities held in the name of declarant and benecially owned by him)
Date(s) of
Date(s) on which the securities were
Number of securities
securities
Amount of securities
acquired by the declarant(dd/mm/yyyy)
(dd/mm/yyyy)

SCHEDULE-III
(Details of the sums given by the declarant on interest)
Name and address of the
person to whom the sums are
given on interest

Amount of
sums given
on interest

Date on which the sums were given on

interest(dd/mm/yyyy)

Period for which sums were

given on interest

Rate of
interest

SCHEDULE-IV
(Details of the mutual fund units held in the name of declarant and benecially owned by him)
Name and address of the
Income in respect of
Number of Class of units and face value of each
Distinctive number of units
mutual fund
unit
units
units

SCHEDULE-V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Oce where the account under the National Savings Scheme
is maintained and the account number

Date on which the account

was opened(dd/mm/yyyy)

The amount of
withdrawal from the
account

.
**Signature of the Declarant
Declaration/Verication

*I/Wedo hereby declare that to the best of *my/our knowledge and belief what is stated above is correct, complete and is truly stated. *I/We
declare that the incomes referred to in this form are not includible in the total income of any other person u/s 60 to 64 of the Income-tax Act, 1961. *I/We further,
declare that the tax *on my/our estimated total income, including *income/incomes referred to in Column 22 above, computed in accordance with the provisions
of the Income-tax Act, 1961, for the previous year ending on .................... relevant to the assessment year ..................will be nil. *I/We also, declare that *my/our
*income/incomes referred to in Column 22 for the previous year ending on .................... relevant to the assessment year .................. will not exceed the maximum
amount which is not chargeable to income-tax.
Place:
Date:

.
Signature of the Declarant

..
..

PART II
[For use by the person to whom the declaration is furnished]
2. PAN of the person indicated in Column 1 of Part II
1. Name of the person responsible for paying the income referred to in Column 22 of Part I
3. Complete Address
4. TAN of the person indicated in Column 1 of Part II
5. Email

6. Telephone No. (with STD Code) and Mobile No.

8. Date on which Declaration is Furnished

(dd/mm/yyyy)

9. Period in respect of which the dividend has been

declared or the income has been paid/credited

12. Date of declaration, distribution or payment of dividend/withdrawal under the

National Savings Scheme(dd/mm/yyyy)

7. Status
10. Amount of income paid

11. Date on which the income

has been paid/
credited(dd/mm/yyyy)

13. Account Number of National Saving Scheme from which withdrawal has
been made

Forwarded to the Chief Commissioner or Commissioner of Income-tax

Place:
Date:

..
.

Signature of the person responsible for

paying the income referred to in
Column 22 of Part I

Notes:
1.
2.
3.
4.
5.

The declaration should be furnished in duplicate.

*Delete whichever is not applicable.
#

Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a rm) under section 197A(1A).
**Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
Before signing the declaration/verication , the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all
respects. Any person making a false statement in the declaration shall be liable to prosecution under 277 of the Income-tax Act, 1961 and on conviction be
punishablei) In a case where tax sought to be evaded exceeds twenty-ve lakh rupees, with rigorous imprisonment which shall not be less than 6 months but which
may extend to seven years and with ne;
ii) In any other case, with rigorous imprisonment which shall not be less than 3 months but which may extend to two years and with ne.

6.

The person responsible for paying the income referred to in column 22 of Part I shall not accept the declaration where the amount of income of the nature referred
to in sub-section (1) or sub-section (1A) of section 197A or the aggregate of the amounts of such income credited or paid or likely to be credited or paid during the
previous year in which such income is to be included exceeds the maximum amount which is not chargeable to tax.";

To,
Regional Provident Fund Commissioner
Chennai 14

Sub: PF Withdrawal - .

Respected Sir,
I .have resigned from the services of Cognizant Technology Solutions on ..
I have applied for PF withdrawal of my PF account (...) with RPFO
Chennai. Considering my PF withdrawal request kindly credit my PF accumulations in the bank account
as mentioned in my PF closure forms (enclosed herewith).

Date:

Yours truly

(X)

Signature of the member

Dear Associate,
Please be informed that as per the EPFO rule, PF withdrawal can be applied for only if:
The PF Claim is submitted after two months from the date of leaving services
You are not employed in any establishment to which the PF act applies
The rule as per EPFO has been provided below for your reference. You are required to provide a
declaration that you have understood the same.
In the case of submission of application for settlement under clause (S) of sub-paragraph (i) and in
clause (b) of sub paragraph (2) of Paragraph 69 of the EPF Scheme, 1952, the claim should be submitted
after two months from the date of leaving services provided the member continues to remain unemployed in an establishment to which the act applies.
I hereby confirm that I have understood the above rule.
NAME:

DATE:
SIGNATURE

PERSONAL CONTACT DETAILS

ASSOCIATE ID

AssociateID

ASSOCIATE NAME

PERMANENT ADDRESS

PERSONAL E-MAIL ID
PHONE NO (Mandatory)
Mobile:
Landline:

Two copies of Form 15G must be filled manually and submitted along with
two self-attested PAN card copies.
(Failing to furnish these will result in TDS being deducted from your PF amount)

Form No-15G
As per the Income Tax Act, 1961, Income Tax shall be deducted at source (TDS) at the
following rates if at the time of payment of the accumulated PF balance is more than or equal to
Rs.30,000/-, with continuous membership with PF less than 5 years:

TDS will be deducted @ maximum marginal rate (i.e. 34.608%) if a member fails
to submit PAN and Form No 15G or 15H (Senior Citizen).

TDS will be deducted @ 10% provided PAN is submitted.

No tax deduction if both PAN and Form 15G/H declared.

Form 15G and 15H may not be accepted if amount of withdrawal is more than
Rs. 2,50,000/- and Rs. 3,00,000/- respectively.

You need to sign under **Signature of the Declarant.