Pf Withdrawal From R.P.F.C Form 19

Pf Withdrawal From R.P.F.C Form 19 screenshot

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Regn. No.................................... Employees' Provident Fund Scheme, 1952 Form-19 (Refer to instruction)1.Name of the members in Block Letters.2.Father's Name or (husband's Name in the case of married woman)3.Name & Address of the Factory/Establishmentin which the member was employed.4.Account No.:…………………….DL. /5.Date of leaving service6.Reason for leaving service7.Full Postal Address (in Block Address) Shri/Smt./Kum................................................................................S/O/W/O/D/O..................................................................................Pin :8.Mode of remittance Put a tick ( √ ) in the box against the one opted(a) By Postal Money Order at my cost.( )To the address given against item No. 7(b) By account payee cheque sent( )S.B. Account No...........................................Direct for credit to my S.B.Name of the Branch.....................................A/c (Scheduled Bank/P.O.)Branch..........................................................Under intimation to me.Full address of the branch........................... (Advance Stamped Receipt furnished)Certified that the particulars are true to the best of my knowledge.Date of joining of Establishment.........................................................................Date of Birth ......................................................................................................Contribution for the Current Financial Year.Period of Period of break MonthContributionbreak if anyMonthContributionif anyEmployeeEmployersTotalEmployeeEmployersTotalMonthWagesMonthWagesEPFFPEPFFPEPFFPEPFFPEPFFPEPFFP ( information to be furnished by the Employer if the Claim Form is Attested by the Employer)Certified that the above contributions have been included in the regular monthly remittances.The Applicant has signed/Thumb impressed before me. ............ ..................................................... Signature of Left/Right hand thumb impression of the member Date......................................Designation & SealEncl.Declaration of non-employmentNote:-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 besubmitted after two months from the date of leaving service provided the member continues toremain unemployed in an establishment to which the Act applies.Date.............. ........... Signature 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 Rs. ....................(Rupees .......................................................... .......................... fromRegional 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. The space should be left blank which shall be filledAffix 1/- Rupeein by Regional Provident Fund Commissioner/OfficerRevenuein-Charge of S.A.O.StampSignature orLeft / 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/24/219 & withdrawal register.Clerk Section SupervisorP.I.No.------------------------------------------------------------------------- M.O./Cheque ----------------------------------Account No. ----------------------------- Section ------------------------ passed for payment for Rs.-------------------¼in words)-------------------------------------------------------------------------------------------------------------------------------M.O. Commission (if any) AOC/APFC-----------------------------------Net Amount to be paid by M.0……………………………Date………………..(For use in Cash Section)Paid by inclusion in Cheque No................................. ............................ date.................................................vide Cash Book (Bank) Account No.3 Debit Item No ............................................... HC AC / RCRemarks