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Form 19

This document appears to be a form for employees to request settlement of their Provident Fund Account. It requests information such as the employee's name and father's name, address, account number, date of leaving service and reason for leaving. It also asks for the employee's full postal address and their preferred mode of receiving payment, either by postal money order or direct deposit to their bank account. Fields are provided to fill in contribution details by month. The employer section is for the employer to certify contributions have been correctly remitted. The employee signs or provides their thumb impression before a witness. Notes provide instructions on submission and timelines.

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Kuldeep Yadav
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86 views2 pages

Form 19

This document appears to be a form for employees to request settlement of their Provident Fund Account. It requests information such as the employee's name and father's name, address, account number, date of leaving service and reason for leaving. It also asks for the employee's full postal address and their preferred mode of receiving payment, either by postal money order or direct deposit to their bank account. Fields are provided to fill in contribution details by month. The employer section is for the employer to certify contributions have been correctly remitted. The employee signs or provides their thumb impression before a witness. Notes provide instructions on submission and timelines.

Uploaded by

Kuldeep Yadav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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/Establishment


in which the member was employed.

4.

Account No.:.DL.

5.

Date of leaving service

6.

Reason for leaving service

7.

Full Postal Address (in Block Address)

Shri/Smt./Kum.............................
...................................................
S/O/W/O/D/O..............................
....................................................

Pin :
8.

Put a tick ( ) in the box against the one opted

Mode of remittance

(a) By Postal Money Order at my cost.

To the address given against item No. 7

(b) By account payee cheque sent


Direct for credit to my S.B.
A/c (Scheduled Bank/P.O.)
Under intimation to me.

S.B. Account No...........................................


Name of the Branch.....................................
Branch..........................................................
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.
Month
Employee
Month

Contribution

Period of
break if any

Employers

Total

Month
Employee

Wages

Month
EPF

FP

EPF

FP

EPF

FP

Contribution

Period of break
if any

Employers

Total

Wages
EPF

FP

EPF

FP

EPF

FP

( 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 & Seal
Encl.
Declaration of non-employment
Note:-

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 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.

Date.............. ...........

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 / 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 filled
in by Regional Provident Fund Commissioner/Officer
in-Charge of S.A.O.

Affix 1/- Rupee


Revenue
Stamp

Signature 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.
Section Supervisor
Clerk
P.I.No.------------------------------------------------------------------------- M.O./Cheque ---------------------------------Account No. ----------------------------- Section ------------------------ passed for payment for Rs.------------------in words)------------------------------------------------------------------------------------------------------------------------------M.O. Commission (if any) AOC/APFC----------------------------------Net Amount to be paid by M.0Date..
(For use in Cash Section)
Paid by inclusion in Cheque No................................. ............................ date.................................................
vide Cash Book (Bank) Account No.3 Debit Item No ...............................................
HC

AC / RC
Remarks

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