Mobile No.

_______________

For Office Use Only

Inward No.:

FORM 19
Employees' Provident Fund Scheme, 1952
FORM TOBE USED BY A MAJOR MEMBER OF THE EMPLOYEES PROVIDENT FUNDS
SCHEMES, 1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES [Para 72(5)]
(Note : Read the instruction carefully before filling of this form)
(All correction / alteration should be attested by employer)

1. Name of the members (in Block Letters)

2. Parent Name (Husbands Name in case of

Married woman)

3. Name and address of the factory/Estb.

In which the member was last employed

4. Code No. & Account No.

:
_____________________________________________________________________________________________
5. Date of leaving service

6. Reason for leaving service

Service terminated on account of a) ill health of member b) contraction c) discontinuation of

employers business or d) other cause beyond the control of the member...............................
............................................................................................................................................................

Personal Reasons: .............................................................................................................................

*6a.

Permanent Account Number (PAN):.

*6b.

Whether submitting Form No. 15G/ 15H of Income Tax (Yes / No):.
(Please enclose two copies of Form 15G/15H, if applicable)
* Only in case of service less than 5 years

7. Full Postal address (in block letters)

Shri / Smt / Kumari / S/o.W/o.D/o

(Please furnish correct address / Information)

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8. MODE OF REMITTANCE (Put a tick
against any one)

M.O.

By Postal Money order at my cost if amount payable exceeds

Rs.500/- (if the amount payable is less than Rs.500/- M.O.
Commission will be borne by the PF Office) if the payment
Exceeds more than Rs. 2000 above will not be made through
M.O.
By account payee cheque sent direct for credit
to my SB A/c.(any Scheduled Bank / Post Office
/ Co-operative Bank) under intimation to me
(Advance stamped receipt furnished below)

Cheque

To the address given in item No. 7

S.B.Account No.___________________________
Name of the Bank __________________________
Full Address of the Bank ____________________

Please furnish S.B.A/c No. duly obtained in any

Nationalised Bank/Schedule Bank/Co-operative
Bank with full Postal Address of the Bank

_________________________________________
_________________________________________

IFSC Code.___________________________

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

DATE OF BIRTH / AGE

DATE OF JOINING THE ESTABLISHMENT

DATE OF LEAVING SERVICE

Certified that the particulars of the member given are correct and the member has signed / thumb impressed
before me.
Date :

*
Signature / left hand thumb impression
of the member

Signature of the Employer with seal

Note:- 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 service provided the member continues to remain unemployed in an establishment to which the
Act applies.

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ADVANCE STAMPED RECEIPT

(To be furnished only in case of 8 (b) above)
Received a sum of Rs.*.................... (Rupees *.......................................................... ..........................
from The Regional Provident Fund Commissioner / Officer-in-Charge of Sub-Accounts Office ..
. by deposit in my Savings Bank account towards the settlement of my Provident Fund Account.

Affix
Re.1/Revenue
Stamp

The space should be left blank which shall be filled by

Employees Provident Fund Office

*
Signature or Left hand thumb impression
of the member on the Revenue Stamp
_____________________________________________________________________________________________

(FOR THE USE OF COMMISSIONER'S OFFICE)

A/C Settled in part/Full Entered in F. 21-A/24/219 & withdrawal register.

Clerk

Section Supervisor

(Under Rs. _______________________________________________________________________________ Only)

P.I.No_______________ M.O./Cheque ______________ Account No. KN / BN /________________
Section __________

Passed for payment for Rs.___________ (in words) Rupees (____________________

_____________________________________________________________________________________ only )
M.O. Commission (if any) ___________________________ Date _________________
Net Amount to be paid by M.O_____________________________________________________________________
EE

ER

Total

Interest up to
Amount Authorised

Date :

A.A.O./A.P.F.C.

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FOR USE IN CASH SECTION

Paid by inclusion in Cheque No................................. ............................ Date.................................................
vide Cash Book (Bank) Account No.3 Debit Item No ...............................................

C.W
S.S.
A.A.O
A.P.F.C. / R.P.F.C.
__________________________________________________________________________________________

REMARKS

Acknowledgement received on __________________________ Verified on _______________________

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