Professional Documents
Culture Documents
Mobile No._________
3.
Name
&
Address
of
the
Account No.:.:
5.
6.
........................................
Personal Reasons:................................................................................................................................
..............................................................................................................................................................
*6a.
*6b.
7.
Shri/Smt./Kum.............................
...................................................
S/O/W/O/D/O..............................
....................................................
Pin :
8.
Mode of remittance
Wages
Period of
break if any
Contribution
Employee
EPF
FP
Employers
EPF
Total
FP
EPF
FP
Month
Month
Wages
Employee
EPF
FP
Contribution
Period of break
if any
Employers
Total
EPF
FP
EPF
( information to be furnished by the Employer if the Claim Form is Attested by the Employer)
Certifiedthattheabovecontributionshavebeenincludedintheregularmonthlyremittances.
TheApplicanthassigned/Thumbimpressedbeforeme.
............ .....................................................
Date.............. ...........
FP
AC / RC
Remarks