COMPOSITE CLAIM FORM (AADHAR) - …

1 EMPLOYEES PROVIDENT FUNDS ORGANISATION ( ) COMPOSITE CLAIM form (AADHAAR) ( , -11 ( ) , ) (APPLICABLE IN CASES WHERE EMPLOYEES COMPLETE DETAILS IN form -11 (NEW), AADHAAR NUMBER AND BANK ACCOUNT DETAILS ARE AVAIALABLE ON UAN PORTAL AND UAN HAS BEEN ACTIVATED) 19 ( ) / 10 ( ) / 31 ( ) [ form NO. 19 (PF FINAL SETTLEMENT) / 10C (PENSION WITHDRAWAL BENEFITS) / 31 (PF NON-REFUNDABLE ADVANCE)] 1 CLAIM applied for: ( , ) (Tick whichever applicable) i) /Final PF Settlement ( ) ii) / Pension Withdrawal Benefits ( ) iii) P F Non-Refundable Advance ( ) 2 ( ): Name of the member: (IN CAPITAL LETTERS) 3 ) /(a) Father s Name: ) /(b) Husband s Name: 4 ( ) ( ) / Universal Account Number(UAN) ( ) Account No 5 / Aadhaar Number.

2 6 / Date of joining the establishment: 7 ) ( , ) Purpose of PF Advance: (Tick whichever applicable) ) ( )/ Amount (in Rs.): _____ ) / / For purpose of Site/House/Flat or Construction through agency or Repayment of Housing Loan or LIC, indicate cheque to be drawn in favour of and payee s address. SN / Purpose of Non-refundable PF Advance i / / / / / ( 68 /68 /68 ) Housing Loan/Purchase of site/House/Flat or for Construction/Addition, alteration in existing house/Repayment of Housing loan (Para 68B/68BB/68BC) ii ( 68 ) / Lockout or closure of factory (Para 68H) Iii ( 68 ) /Unemployment Advance (Para 68HH) iv / ( 68 )/ Illness of member/family (Para 68J) v / / / / ( 68 ) / Marriage of self/son/ daughter/brother/ sister (Para 68K)

3 Vi ( 68 ) / Post Matriculation education of children (Para 68K) vii ( 68 ) / Natural calamity (Para 68L) viii ( 68 ) / Cut in electricity in establishment (Para 68M) ix ( 68 ) / Purchasing equipment by physically handicapped (Para 68N) x ( 68 ) / One year before retirement (Para 68NN) xi ( 68 ) / Investment in Varistha Pension BimaYojana (Para 68 NNN) 8 ( / )) Date of leaving service: (not required if applying for PF Advance) 9 ) ) ( ( 5 ) ( 15 /15 , ) Permanent Account No.

4 (PAN): (Only in case of service less than 5 years) (Please enclose two copies of form No. 15G/15H, if applicable) ) / Reason of leaving Service: - ( ) ( ) ( ) Service terminated on account of (a) ill health of member (b) Contraction /Discontinuation of employer s business or (c) Other Cause beyond the control of the member - / Personal Reasons 10 Full Postal address - 11 ( )

5 , ( , ) Certified that the particulars are true to the best of my knowledge. I certify that I have gone through the data seeded in UAN Portal and found all data, including form (New), bank account details and aadhar number, to be correct. Please make the payment in the bank account mentioned in the UAN Portal. A cancelled cheque (containing member s name, bank account number and IFS Code) is attached herewith. - (7) In case the amount is used for any purpose other than stated in column (7) above, I am liable to return the entire amount with penal interest.

6 Member s Signature / Mobile Number- - /E-mail - ---------------------------------------- -------- ( ) INSTRUCTION FOR FILLING THE COMPOSITE CLAIM form (AADHAAR) ( ( ) -11 ( ) , .. ) (The COMPOSITE CLAIM form (Aadhaar) is applicable in cases where a member s complete details in form -11 (New), aadhar number and bank account details are available on the UAN Portal and UAN has been activated. Such members can submit this form directly to the concerned EPFO office, without attestation of CLAIM form by the employers.)

7 1. :- The application can be made for : i) / Final Settlement ii) ( 1 ) Pension Withdrawal Benefits (only if the service is less that 10 years) iii) / PF Advance, / Tick the boxes accordingly. 2. : / Name : Name in CAPITAL LETTERS 3. ) : / a) Father s Name : Kindly write clearly. ) : / b) Husband s Name: Kindly write clearly. 4..: 12 / UAN: Please mention the 12 digit Universal Account Number. 5.

8 /Kindly mention 12 digits Aadhaar Number 6. : / / / Date of Joining the establishment: In DD/MM/YYYY format 7. :- Purpose of PF Advance and Amount required: / The purpose may be one of the following: i) / / / / / / : ( / ) Housing Loan/purchase of site/house/flat or for construction/Addition alteration in existing house/Repayment of Housing loan: No document is required.

9 No document ( New Declaration form /Utilization Certificate etc.) is required. / / In case the advance is for purchase of site/house/flat or construction through Agency or repayment of Housing Loan then indicate the name in whose favour the payment has to be made. ii) / Lockout or closure of factory: /No document is required iii) Unemployment advance: /No document is required. iv) / /Illness of member/family: / No document is required.

10 V) / / / / /Marriage of self/son/daughter/brother/sister: ( ) /No document ( Marriage Card) is required. vi) /Post Matriculation education of children: /No document is required. vii) /Natural calamity of exceptional nature: /No document is required. viii) /Cut in electricity in establishment: /No document is required. ix) /Purchase of equipment by physically handicapped: /No document is required.