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PF Form 19 &amp 10C (Speciman Copy)

1. The document is an application by AAAA for claiming Employees' Provident Fund and Pension Scheme dues. AAAA was last employed at Genpact India in New Delhi from May 2000 to September 2003. 2. AAAA provides contact information and bank account details for refund of dues via postal money order or account payee cheque. Employment and contribution details during service are also provided. 3. AAAA declares no current employment and seeks settlement of Provident Fund and Pension Scheme accounts to withdraw dues.

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teniya
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840 views

PF Form 19 &amp 10C (Speciman Copy)

1. The document is an application by AAAA for claiming Employees' Provident Fund and Pension Scheme dues. AAAA was last employed at Genpact India in New Delhi from May 2000 to September 2003. 2. AAAA provides contact information and bank account details for refund of dues via postal money order or account payee cheque. Employment and contribution details during service are also provided. 3. AAAA declares no current employment and seeks settlement of Provident Fund and Pension Scheme accounts to withdraw dues.

Uploaded by

teniya
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Regn. No.

EMPLOYEES PROVIDENT FUND SCHEME, 1952


(Refer to Instruction)

Form 19

For Office use only

Application by an Adult Member of the Employees Provident Fund Scheme, 1952 for Claiming the Employees Provident Fund Dues

Name of the member (In Block Letters)

AAAA

2. Fathers Name or (husbands name in the case of married woman) BBBBB Name & Address of the Factory/ Establishment Genpact India, DMRC, IT Park , Shastry Park, New Delhi - 110053 in which the member was last employed 4. PF Account No. DL/20846/3987

3.
In

5. Date of leaving service 6. Reason for leaving service

10-Sep-2003 RESIGNATION Shri/ Smt. Kum. : . S/o. W/o., D/o: (Complete Mailing Address) . Pin: .

7. Full Postal Address (in Block Letters)

Put a tick (4 ) in the box against one opted To the address given against item No. 7. S.B. Account No. . Name of Bank/Branch . Full address of the Branch . Certified that the particulars are true to the best of my knowledge. Date of Joining the Establishment 17-May-2000.. Date of Birth .. Contribution for the Current Financial Year Sl. Month Wages Contribution Period of Break, No. if any Employee Employer Total EPF EPS EPF EPS EPF EPS

8. Mode of remittance (a) By Postal Money Order at my cost (b) By Account payee cheque sent Direct for credit to my S.B. A/c (Schedule Bank/PO) Under intimation to me

( ( ( (

) ) ) )

(Information to be furnished by the Employer if the Claim Form is Attested by the Employer) Certified that the above contributions have been included is the regular monthly remittances. The Applicant has signed / thump impressed before me. ... (Sign) Signature of Left/ Right hand thump impression of the member Signature of the Employer or authorized Officer Designation & Seal: Date : . 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 2 months immediately proceeding the date of my application for final withdrawal of my Provident fund money. (Sign) Date : Signature of Left/Right hand thump impression of the member ADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above) Received a sum of *Rs. .. (Rupees .) From Regional Provident fund Commissioner / Officer-in Charge of Sub-Accounts Office .. By deposit in my Saving Bank account towards the settlement of my Provident Fund Account

(Sign)

Signature of left / Right hand thump impression of the member (For the use of Commissioners Office) A/c Settled in part/Full Entered in F.21-A/24/2/9 & withdrawal register. Clerk (under Rs.) Head Clerk

P.I. No. . M.O./ Cheque .. Account No. Section .. / passed for payment of Rs. in wards ... M.O. Commissioner (if any) AAO/APFC Account Officer Net Amount paid by M.O. . Date . (For use in Cash Section) Paid by inclusion in Cheque No. date .. Vide cash Book (Bank) Account No. 3 Debit Item No. H.C. Remarks AC/RC

FORM 10-C (EPS)

EMPLOYEES PENSION SCHEME, 1995


FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
1. (a) Name of the member (In Block letters) (b) Name of the claimant(s) 2. 3. 4. Date of Birth Fathers Name Husbands Name (If applicable) AAAAA AAAA . . BBBBB . . Genpact India -----------------------------------------------------------------------------------------------------------------------------------------------------------------Region / SRO Code DL/20846/6987 Estt. Code No. A/c No. Resignation, 10, Sep-2003 8. Full Postal Address (In Block Letters) Sh. Smt. Km. S/o, W/o, D/o Complete Mailing Address . .. PIN . 9. Are you willing to accept Scheme Certificate in Lieu of withdrawal benefits (a) Yes (b) No(Please tick No)

5. Name & Address of the Establishment in which, the member was last employed 6. Code No. & Account No.

7.

Reason for leaving service & Date of leaving

10. (a) (b) 11.

Particulars of Family (Spouse & Children & Nominee)


Name Date of Birth .. .. Relationship with member .. .. Name of the guardian of minor

Family Member Nominee

..

In case of death of member after attaining the age of 58 years without filing the claim: (a) (b) Date of death of the member Name of the Claimant(s) / and relationship with the member

12.

Mode for Remittance [Put a Tick in the Box against the one opted] (a) (b) By Postal money order at my cost to address given against item No. 7 Account payee cheque sent direct for direct to my SB A/c (Schedule Bank) Under intimation to me. S.B. Account No. Name of the Bank (in block letters) Branch (in block letters) Full address of the Branch (in block letters)
111111111111111 ICICI Bank Name of the branch . Complete address of the Branch in which the account is held .

13.

Are you availing pension under EPS 95? Not Applicable If so, indicate PPO No. By whom issued ..

Certified that the particulars are true to the best of my knowledge.

(Sign)
Signature or Left Hand Thump Impression Of the Member / claimant(s)

Date:

ADVANCE STAMPED RECEIPT


[To be furnished only in case of 12 (b) above] Received a sum of Rs. (Rupees ..) only from Regional Provident Fund Commissioner / Officer in charge of Sub- Regional Office . By deposit in my savings Bank A/c towards the settlement of my Pension Fund Accounts. (The Space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer-in-charge)

(Sign)
Rs. 1/Revenue Stamp

Signature or Left Hand thump Impression Of the Member on the stamp

Certified that the particulars of the member given are correct and the member has signed / thump impressed before me. The details of wages and period of non-contributory service of the member are as under: Form 3A/7 (EPS) enclosed for the period for which it was not sent to employees Provident Fund Office.

Wages (Basic + D.A) as on 15.11.95 (if applicable) Wages as on the date of exit.

Period of non-contributory Service Year / Month No. of days

Date: . Signature of Employer/ Authorised Official

(FOR THE USE OF COMMISSIONERS OFFICE)


Under Rs. P.I. No. M.O. / Cheque. Passed for payment for Rs. ( in words) ... M.O. Commission (if any) net amount to be paid by m.O. . towards withdrawal benefits.

D.H.

S.S.

A.A.O.

(For use in Cash Section) Paid by inclusion in cheque No. .. Dt. vide cash Book (bank) Account No. 10 Debit item No.

D.H. For issue if S.S.,: IDS is enclosed.

S.S.

AC (A/cs)

D.H.

S.S.

A.A.O./APFC (A/cs)

(For use in Pension Section) Scheme Certificate bearing the control No. issued on .. and entered in the Scheme Certificate Control Register.

D.H.

S.S.

A.A.O. APFC (PENSION)

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