Regn. No. Employees’ Provident Fund Scheme, 1952 Form-19 (Refer to instruction) 4._Name of the members in Block Letters. MANADEVKALA TASMIN LPENDRA 2 Fathers Name or (husband's Name inthe case of maried WO") wav wnevinen vrewoen 3. Name & Address of the Factory/Establishment inwhich the member was employed, 4. Account No, DL. L 5. Date ofleaving service 6 Reason for leaving service 7. Full Postal Adress (in Block Address) ShlSmt Kum: 2NhSS, euPAT- stREET, 6 AORAMPU RA, SURAT, SIOMODIO. Gusere7, pA Sls [sole [2] Pin 8. Mode of remittance Puta tick ( 1) 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 (1 SB AccountNo. F2. 62528 hove 726 OL Direct for credit to my S.B. Name of the Branch..4.0,.8.MA. TAKA, @AvK LED. ‘Ne (Scheduled Bank 0) Branch se 7 Under intimation to me. Full address of the branch...) A@AD, Sue AT was oe (Advance Stamped Receipt fumished) SS Cert that he particulars are tue tothe best of my knowledge Date of joining of Establishment. é Date of Birth i ~ S __Contrbuton forthe Gurent Financial Year. | Pesiod ot ] Treoder trent Hoth ___| contuson | sent any Month | Contribution | "fan | |_Employee Employers Total | Employee Employers Total | Month | Wages [~~ | 1 monn | wages (= aoe L _jere_|rp|epr rp | epe | ep cpr | ep |epr | rp | epr(information to be furnished by the Employer if the Claim Form is Attested by the Employer) Cettified that the above contributions have been included in the regular monthly remittances. ‘The Applicant has signed/Thumb impressed before me. Tasmin Ypenelin Signature of LeftiRight hand thumb impression of the member Date. Designation & Seal Bre, ny ti Declaration of non-employment Note:- In the case of submission of application for settlement under clause (s) of sub-paragraph () and in clause (b) of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1952, the claim should be submitted after two months from the date of leaving service provided the member continues to remain unemployed in an establishment to which the Act applies. Taser percha Date... 1.05 [200 ‘Signature or Left/ Right hand 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 Regional Provident Fund Commissioner / Officerin-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 filed in by Regional Provident Fund Commissioner/Officer in-Charge of S.A.0. Signature orLeft/ Right hand thumo impression of the miémber (For the use of Commissioner's Office) AC Settled in part/Full Entered in F. 21/24/29 & withdrawal register. Ss Clerk . Section Supervisor PINo— —— M.OCheque ~ Account No, ———————~--=- Section ——-—--—_ passed for payment for Rs.— lin words}~ = M.O. Commission (if any) AOC/APFO—————- Net Amount to be paid by M.0. Date. (For use in Cash Section) Paid by inclusion in Cheque No. és date, vide Cash Book (Bank) Account No.3 Debit tam No He AC IRC RemarksSerial No: For Office Use Only In Words No, Form No. 10 C (E.P.S) EMPLOYEES’ PENSION SCHEME, 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE Fe filling up this a) Name ofthe member: MAKAOEV WALA TAFMIN Yerwor a (in Block Letters) pNemostihedainent(e) mann devicnth gasmiv LeeNnea Date Of Birth Py) CBI a) Father's Name manndevwerA vReWPRA 3 'b) Husband's Name —_— (if applicable) ” Name & Address of the Establishment in which, the member was last employed Code No. & Account No. Region/SRO Codd Est, Code No. Alc No. Reason for leaving service & Date of leaving Full Postal Address ((n Block Letters) DN keas, puPar- eer Sh/Smt/Km_ BAGRAMPURA, SURAT Slo, Wo, Dio Tuseaet (VOL PIN_3 3S COD8. Are you wiling to accept Scheme @ ©) Cerificate in eu of withdrawal benefits yes nol] 98. Paiculars of Family (Spouse & Children & Nominee) Name Date ofBith Relationship With Member Name of the guardan of minor D Fay TT mensagverin UPEND RA = 16 /9INE? — FATHER Members pmananevimn ViaAl ~ O1fos 19eF— GRUNER setnawer were SMLVEE- ag] ee7igbo — WIFE (&) Nominee C aADevWAle Tyo TsHAAaen — 30 /agliggay MOTHER 40. Incase of death of member after attaining the age of 58 years without fling the claim:- (@) Date of death of the member {3 Name of the Claimant(s)/ and relationship with the members 4, MODE FOR REMITTANCE [PUT A TIC IN THE 80X AGAINST THE ONE OPTED) {@) By postal money order at my costo adress given against item No, 7 oO ) ‘Account payee cheque sent direct for credit to my: SB Alc (Scheduled Bank) under intimation tome S.B. Accounts No pre 25001 wo F260L Name of the Bank ppawerabe BAve ITD (in block letters) Branch pat {inbiock letters) Sue 8 eso Full Adcress Of the Branch RIND ROAD S. {inblock letters) eo Sy eet — 385 Or ee 12, Are your avaling pension under EPS-95 ? If so indicate PPO NO. By Whom Issued Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE Date 0 log (20 Signature or left Hand ‘Thumb Impression of the Member /claimant(s) Susmen pend reADVANCE STAMPED RECEIPT [To be furnished only in case of (b) above] Received a sum of Rs. (Rupees. ) Only from Regional Provident Fund Commissioner /Otficer-in charge of Sub-Regional Office by deposit in my savings Bank Alc 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) Signature & left hand thumb impression of the member on the stamp Certified that the particulars of the member given are correct and the member has signed/thumb 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 employee's Provident Fund Office) Wages (Basic + D.A) as on 15.11.85(if applicable) ‘Wages as on the date of exit Period of non contributory Service YeariMonth No.of days, iene Date. ‘Signature of Employer’ authorised Official(FOR THE USE OF COMMISSIONER'S OFFICE) (Under Rs. P.l.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 benefit. DH. ss AAO (FOR USE IN CASH SECTION) Paid by inclusion in cheque No. Dt vide cash Book(Bank) Account No. 10 Debit item No, DH Ss AC(Alcs) For issue if SS;. IDS is enclosed DH ss A.AOIAPFC(Ales) © (FOR USE IN PENSION SECTION) ‘Scheme Cerificate bearing the control No Issued on and centered in the scheme Certificate Control Register- DH ss AAO ‘APFC(PENSION)w4eass?m 39505200 a1 a0bo Karnataka Bank Ltd. ‘ACILITIES FOR SB ACCO! Ri SB Ae can be opened in the name of an individual, joint nAmes, HUF minor represented by a guardian. Accounts also can be opened in tha name of Trust / Association / Society. Club subject to compliance of necessary conditions as per FBI direction. t Nomination facilty is available only for Individuals. Interest at 2% above Saving Bank Rate will be paid in case collection of outstation instruments is delayed beyond 14 days, except under circumstances beyond our control. Such interest may be paid when the amount is As. S/- or more, ‘On compliance of certain requirements, immediate credit is given to all outstation / local instruments dravin in your favour upto As, 15, O0O/- IMTTs upto Rs, 2,500/- per day for credit of SB Alc are allowed - ATPAR, Insurance Cover available unider Insurance linked Saving Bank Account Scheme. In all the net worked branches of the Bank Debit Cards will be issued to Account holder at fe of cost. SAVINGS BANK AIC NO.: 7262500100072601 NAME & ADDRESS OF THE ACCOUNT HOLDER/S 1.HR JASMIN UPENDRA MAHADEVWALA 2/1495, POPAT STREET SAGRAMPURA, SURAT 395002 INDIA OPERATIONAL INSTRUCTIONS MINOR AND NATURAL BRANCH : SURAT BUSINESS HOURS WEEKLY HOLIDAY : UA