EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952

Sl.No....
Regn.No.

Form 19

Supplied free of cost

FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES' PROVIDENT FUNDS SCHEME 1952
FOR CLAIMING THE EMPLOYEES' PROVIDENT FUNDS DUES [PARA 72(5)]

1. Name of the member (in Block letters)

SHAHID

2. Father's Name or Husband's Name(in case of married woman)

MUHAMMED

3. Name & Address of the factory/establishment in

which the member was last employed

CYBROSYS TECHNO SOLUTIONS,KINFRA

NEO
SPACE,KAKKANCHERY,MALAPPURAM,EE,E
E,6789089

4. P.F.Account No.

NE/AGT/0003455/123/7

5. Date of leaving Service

01/Jun/2011

6. Reason for leaving service

Voluntary Retirement

7. Full postal address( in Block letters)

Address

Sri/Smt/Kumari

SHAHID
...................................................................

S/o /W/o /D/o

MUHAMMED
...................................................................

CHEMMAD,PARAPPANANGADI,MALAPPURAM,MALAPPURAM,KERALA,589652
.......................................................................................................................................................
PIN Code

8. Mode of remittance
Put a "Tick" in the box against the one opted
To the address given against No.7
(a) By postal money order at my cost
(only if the amount is less than Rs.2000)

(b) By account payee cheque sent direct for credit

78787

S.B.Account No.

to my S.B.A/c (Scheduled Bank / Co-operative

Bank) under intimation to me

Name of the Bank

SBI
............................................

Branch

Parappanangadi
............................................

Full address of the branch

Parappanangadi
.................................................................................
................................................................................

2009 March............
Contribution for the current financial year from April...................to

Worker's Share

Month
Amount
of
wages

EPF
10%/
12%

Employer's Share
EPF
difference
between
8.33%
&
10%/12%

Pension
Fund
8.33%

Refund
of
Advance

No. of
days
of noncontributing
servie
if any

2010

Worker's Share

Employer's Share

Amount
of
wages

EPF
difference
between
8.33%
&
10%/12%

Month
EPF
10%
/12%

Pension
Fund
8.33%

Refund
of
Advance

No. of
days
of noncontributing
servie
if any

April

Oct

May

Nov

Jun

Dec

1,000.00

120.00

37.00

83.00

0.00

0.00

July

Jan

1,000.00

120.00

37.00

83.00

0.00

0.00

Aug

Feb

1,000.00

120.00

37.00

83.00

0.00

0.00

Sept

Mar

1,000.00

120.00

37.00

83.00

0.00

0.00

Total

4,000.00

480.00

148.00

332.00

0.00

0.00

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

Date of joining the establishment

Date of leaving service

.....23 May 2008.......................

......01/Jun/2011.......................

(Information to be furnished by the employer if the claim form attested by the employer)

Certified that the above contributions have been included in the regular monthly remittances.

The applicant has signed / thumbed before me.

Signature or left thumb impression of the member

Signature of the Employer or authorised

official with designation and seal
Date: 06/01/11

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 of
not less than two months immediately preceeding the date of my application for final withdrawal of my Provident Fund
money.

Date:..............................

Signature of left hand/right thumb impression of the member

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 SubRegional Office......................................
.................................................................. by deposit in my savings bank account towards the settlement of my
provident fund account.

* The space should be left blank which shall be filled by Regional Provident Fund Commissioner /
Officer- in - charge of SRO.

Affix Re.1
Revenue
Stamp

Signature or left / right hand thumb impression of the member

FOR THE USE OF COMMISSIONER'S OFFICE

A/c. settled in part / Full .Entered in F.21 A/24/2/9 & Withdrawal Register
Clerk

Section Supervisor
P.l.No.............................M.O./Cheque

(Under Rs...........................)
Account No.

Section A. B................................

.................................................................
Passed for payment for Rs.......................(Rupees...................................................................
...............................................................................................................................................)
M.O.Commission(if any)...............................
Net amount to be paid by M.O.......................

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

Date:.........................

(For use in Cash Section)

Paid by inclusion in cheque No................................. vide Cash Book (Bank)

Account No.1 Debit item No......................................................................
AAO/APFC
Remarks
4

RPFC