EMPLOYEES' PROVIDENT FUND SCHEME, 1952 …

1 employee (Personal)For office use OnlyRegd. No. _____EMPLOYEES' PROVIDENT fund SCHEME, 1952 FORM - 19 Form to be used by a major member of the Employees' PROVIDENT fund Scheme, 1952 for claiming the Employees' PROVIDENT fund dues [ Para 72 (5) ]1. Name of the member (in block letters)2. Father's Name (or husband's Name in the case of married women)3. Name and Address of the Factory/Establishment in which the member was last employed4. Account No. (PF No.)5. Date of leaving Service6. Reason of leaving Service7. Full postal address (in block letters) W/o D/oPin Mode of RemittancePut a 'Tick' in Box against the one opted(a) By postal Money Order at my costTo the address given against item No. 7(b) By account payees cheque No.

2 Direct for credit to my S. of the Bank A/c (Scheduled )Full Address of the Branch under intimation to Code of Bank BranchAdvance Stamped Receipt furnished belowCertified that the particulars are true to the best of my of Joining the EstablishmentDate of BirthContribution for the Current Financial YearMonth Contribution Period of Break if anyMonthContribution Period of Break if anyMonthWagesEmployee Employer TotalMonthWagesEmployee Employer TotalMarchSeptemberAprilOctoberMayNovemb erJuneDecemberJulyJanuaryAugustFebruryMe mber's SignatureEmployer's Signature(Information to be furnished by the Employer if the Claim Form is Attested by Employer)Certified that the above contributions have been included in the regular monthly Applicant has signed/thumb impressed before or Left/Right hand thumb impression of the memberDateDesignation & of non-employmentNote:In the case of submission of application for settlement under clause(s) of sub-paragraph(1) and inclause (b) of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1952 , the claim should be submittedafter two months from the date of leaving service provided the member continues to remain un-employed in an estt.

3 To which the Act or Left/Right hand thumb impression of the memberADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above)Received a sum of * (Rupees_____Only) fromRegional PROVIDENT fund Commissioner/Officer-in-Charge of sub-Regional Office_____by deposit in mySaving Bank account towards the settlement of my PROVIDENT fund Space should be left blankwhich shall be filled in by RegionalProvident fund Commissioner,Office-incharge of Sub-RegionalOfficeAffix RupeeRevenue StampSignature 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/2and withdrawal Register/Form 3( ) Form 9 (Revised)ClerkHead ClerkUnder I. NoPassed for Payment for (in words).

4 Commission(if any)Net Amount to be paid by M. OfficerDated(FOR USE IN CASH SECTION)Paid by cheque cash bookand Account No. 10 Debit item / R.