64\ PL, E F .

kri 19
(latr ivixtot
q>iqfvitr 4 crzkrt i f4/ For Office use only
9) '91 tIiitszTF4R1- ztIV91, 1952

.4,0 it/ Mobile Number

1 67
vqr r/Clam I.D

00

EMPLOYEES' PROVINDENT FUND SCHEME. 1952

2.

tt<4 wr 'ITI (FITZ 31E-T0 A) Name of the member (in block letters) 144114i T4111 (fdqlfgcr 411d-ra4 i 4 ri4 1,4 4) Father's/ b.usbaird's Name in the case of married women
-

VI k AS 64-I . S U

ICUMAg.

N / 1--

k 1) M A R..

rtitlleiPT9T 4F

.111 a tEdi Wilii *lq'241 34i

", f

4.
5. 6. 7.

ft-4ff 1-4k4 Trzrr tA/Name and Address of the Factory /Establishment in which the member was last employed. olor 3 4./ Account No.
tWe BYZA ATh -fl '6+- 3-4

i Li

OR l EA/-711 I_ ilEA/CY A , kA k0 L 8 A 0-1 / IV E IN) bEtill - II O 0 o5

t__ C- P /`/// / 1. 27 t3,

Wit/Date of leaving Service air 4,1xur/ Reason of leaving

Service
EM a.14 6H

61.2613 k ',5.XA JP/k 7/6A./ -30/ 413/4triit/T4r3)/ Shri/Smt./Kumari 1-P/A-41 / 3E-41 / S/o/W/o/D/o .. VI kA

Full postal address (in block letters)

S kU

-- A t T/VVA k Pu RI , Alaw bE L111 Pin Nolf4A q)ls

iLl - -c 0 Ni L ku NA.iK.
//0

milk

C/ I.) 44])..

,, ,,- ,..,_

8.

ra-t4 it ftf4/ Mode of Remittance 43 gm/ (a) By Postal (T) 43 tai 43 44134Money Oder at my cost. glitff (g) -TO TLI -d- 4rtt g 43 trtrf elicitizt.(31 40 / l'O tO A 01.):KI - cr)/ Oct5,Ing, 'TT6717 tr 3Tr-4-rdr oicir ttt)- 4r 'lilt/ (b) By account payees cheque/ electronic mode sent Directly for credit to my S.B. A/C (Scheduled Bank /P.O.) Under intimation to me .

0 , 1N gad- Will crw u-'4- tR -31z-- 4 Put a 'Tick' in Box against the one opted ) 44 34. 7 4 ftc 47 1;0 43/ To the address given against item No.7
ovt d" .:1<t) 'calm 34./

fect,

( Ne/ r

S.B Account no

7 3 Olro 6 Ci 6 a I
Ilvh14

44, wt ArA / Name of the Bank strut/ Bran Brch 3rt...cr-fr. ct,)

V \NAKP Oki
/ IFS Code

.STAT.E 8R Afic ,0

6.8.)N OD 23060 Twit wr 17L3r 44T/ Full Address of the Branch A - I ,

Arfrilff 1 , zlr ,yilor t f'iOr tkr4

...TrEFT# 44st

(84tirr twz ci'ft e rfl< l't tt lit t)(Advance Stamped Receipt furnished below) j3A3 \i4x141-r fdckur ,9a t/ Certified that the particulars are true to the best of my knowledge . .41tol4i i 3r/2 O ,3 .2.oci. (dd/mtn/yyyy) ffif4/ Date ofJoinin the Establishment

r tf4/Date of Birth 0 5. =lig I'd a4 wr sign((/ Contribution for the current Financial Year (44
fferd-t atsgm
0.10-11.1 aR arer oft 4t t ff1

06/0'70
Pa al c141 EMPLOYERS
T.,T.1. R.4.

2012-13 tr
,

(dd/mm/yyyy) oil At) (Not applicable from year 2012-13)

Month

Contribution .Mtjf1 4i47r41 Wages EMPLOYEE -

Period of Break if any

Month Wag es

Contribution
9, 41

TOTAL
WAA. 0. ,

EMPLOYEE
TR 4.4.

Period of Break if any q aril T.., EMPLOYERS TOTAL

i
34,:t

qtt.

.,T.

4.4.

11'.

q.4.

P.

FP

EPF

FP

EPF

FP

cy ''' Riot September ara ae October 1 ,111i November Rtp-,K December w9a81 January w-fall February

EPF

Pt. EPF

FP

1'4. EPF

FP

Pt. EPF

FP

wr4 March

April 'T May June ri4 July arrro August

1\fOrtin k7
# FiTTIL97

11191 VtAl
# f)ttichtt 6i-cirffl3 /Employer's Signature P.T.O

3itrat 4-k/T.g Trzt of 3I-TO fAstF Signature or Left / Right hand thumb impression of the member

www.epfindia.gov.in

qf Trzrrt at TF9r qiai wt itictor & Itr (Information to be furnished by the Employer if the Claim Form is attested by the Employer) 11 iifalcT eal wlci1 t 31714-(9 fa uflcr OTT wqr ,<1 r 4 vrrI4F t 1 Certified that the above contributions have been included in the regular monthly remittances.

well 443 ,(1144 Titrat3 f+-7/SPI-d(

(1 4 11241

t/ The Applicant has signed/thumb impressed before me.

61/404 zi <tor 6i-c1Iks1 .1/ Signature of Employer f*1 /Date if ti /01)-0 1a

tiqvi Trra-T NWT A-N/Tq TeT 3#0 Signature or Left / Right hand thumb impression of the member

Designation & Seal of Employer arm/ Encl. twft 4 9 t-4- l 1.41guir/ Declaration of non-employment 314ff 3T1t49. mt1 Arr-ral A 'M.4T 91-- it Rtmuir : z4A-9( 1952 IT 69 37NT (2) tg.4 ((TT) 3P1t 37-171 (1) z vig-d q t rrftnlct *14t-4 c.1 , 11c1H dtlwmH 3-6-r 3m-4( titt 7e1rc(9-r 4 wrtiff tR 3#?ii449 c.+141 ffiftEt T zl 4)4 Note : In the case of submition 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 be submitted after two months from the date of leaving service provided the member continues to remain un-employed in an establishment to which the Act applies.

ffRE /Date /

I 1 6 )

1: 11o,y)ALe to
311t4 fewe ci41T411-4 (m s--4--& \3tNlctvr s(u) 91 ,1c4 at vilq) ADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above)
arcr4 Af4Ezt 1'41r

13

tiqt4

6t.1141't 3P-T7f

q-r/

Ter. 41.0

fZ11-1

Signature or left / Right hand thumb impression of the member

44t4 41'011

3nzive1fsp11t 34--c)r

Pavel -r aR only) from by deposit in my

r 3144 wuct

ur0-

Received a sum of Rs. (Rupees Regional Provident Fund Commissioner/Officer-in-Charge of Sub Regional Office Saving Bank account towards the settlement of my Provident fund Account. tkltzr 4ftsEr MR( 3trzpV74rt ztralttt q iokio gkr 474 t f to.)51 The space should be left blank which shall be filled in by Regional Provident Fund Commissioner, Office-incharge of SubRegional Office. f)Liefri f+-zi1
TRIT

aR

z,virrt
01/1

Affix 1.00 Rupee

tiqter Tirrat-3 Trr 3#0 r 14sTr9 TraT Signature or Left/Right hand thumb impression of the member arrEsr velicv( 101 , 1 fWg/ (For the use of Commissioner's Office) rb-i4 ti. 21v2 -ffETT CruT <DtCq3 A. A. fk AT 9 (-074R1-d) AftZ

A/c. settled in Part/Full Entered in F-21-A/2 and withdrawal Register/ Form 3 (F.P.F.) Form 9(Revised) l'A:4T/ Clerk 3(44/ Under Rs. 3T>1r4 i'MA-T/ Head Clerk 4113tr-43/A-T M.O./Cheque t441 rffri um 140r/ Passed for payment for Rs 31-10m-rft Accounts Officer Dated tlinr Account No.

t)L4

Trd-M 44- T.

P.I- No.

4)/(In words) 4t31Ttq a4lxri 0 1Z q>l 4 t)/ M.O. Commission (if any) s14 .flfir 4tatr43 5 kr t uir-Tr t/ Net Amount to be paid by M.O.

(4 col

-<t) 34. Paid by cheque No.

3r141-4 ;ROT * f'= -7)/ (FOR USE IN CASH SECTION) ft-4(w Date g kr f+-zrr Trzrr I
Ra(r./4.3(r/ A.C./R.C.

, ct, . #1 Vide cash book

and Account No. 1 Debit item No.

31Pr4wrt/ REMARKS