Download form 19 and 10c epf india

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. 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.

Month

Contribution

Period of

break if any

Month

Contribution

Period of break

if any

Employee

Employers

Total

Employee

Employers

Total

Month

Wages EPF

FP

EPF

FP

EPF

FP

Month Wages EPF

FP

EPF

FP

EPF

FP

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( 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.

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. Clerk Section Supervisor P.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 / RC

Remarks

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



(~ ~ lim! ;;Jffi ~)(Supplied free of cost)

Cf>4i11:fl ~ 4)\jf~1,1995EMPLOYEES' PENSION SCHEME, 1995

~-1 0 T[ (cpo tfo mo)Form 10-C (E.P.S.)

PtC6I~ qR<'II~/m\jFlI l'l''lloIQ'5l ~ m %'g 311~C;"1>Jq'5f

Form for claiming withdrawal benefit/scheme certificate

f.tcflT/INSTURCTIONS<I!R ~ 11;;" lfII;(fl t ? / Who Can apply ?1. ~ ~ ~ mwn. 1971/4illfi ~~. 1995~ ~ ~ R;r<A

A Member of the Employees' Family Pension Scheme. 1971/Employees' Pension Scheme. 1995.(q;) 10 Cf!! mI mn ~ m " wl f.!Iq)"1'1 em ~ ~ t(a) Who has left the employment before completion of 10 years service.

(~) 10 Cf!!mI mn 'f'Im"wl mn 1) ~ §II ~ mn fIR ~ 58 Cf!! mI 3Il1j em 'i" "" '¥' m I(b) Who has attained the age of 58 years before completion of 1Oyears service - whether in servicelleft the service('1) "'" 3fCI1t'I ~ <PI'!! <lim 6 '1Ti; 3Ift)q; m I

2. If<!'~. f.lIWt "'" RlT"R mI ~ em 10 Cf!!<Gt "'" ~ "" <ft ~ 3fIx ~ ~ em 1R') mI ~ 0<1>58 Cf!!<Gt ~ em m'<f ~ SlIT t <II ~ ~ ~ 1R') <Gt 3I?I1il 0<Ii 50 Cf!!<Gt ~ m'<f "" ~ t <II 50 ~ <Gt ~~ 3Ift)q; IR'\j 58 <f!i <Gt l51l <Gt 3Il1j em m'<f "" ~ t ~ ~ G< qI') ~ ~ ~ ~ t IA member. who has completed 10 years service on the date of his leaving the service and has not attained the ageof 50 years on the date of filing this application orhas attained the age of 50 years on the date of filing this applicationor has attained the age of 50 years or more but less than 58 years. and not willing for reduced pension.~'1: ~ 1.3.1971" ~ 15.11.950<1> qI') mn (~'i!iW t) ~ 10Cf!! mI mn ~ ~ ~INote-I: To determine the period of 10 years service rendered from 1.3.1971 to 15.11.1995 (if any). shall

also be taken.~-II 0) If<!' ~. ~ 10 <f!i qI') "'" ~ 1!R <ft t 3fIx 58 1f'i qI') ~ em m, 'I3M! mn 1) ~ ~

~ lff'(I "" ~ t. ~ ~ ~ ~ tff?T t INote-II (i) A member who has completed 10 years service and attained the age of 58 years, whether in

service or not is eligible for Monthly Member Pension.(ii) ~ R;r<A 10 <f!i qI') "'" ~ 1!R <ft t ?1m 50 Cf!! (I\) 3Il1j '>fi ~ 1!R <ft t ~ ~ 

~~G<1:R~~<i;~tff?Tt I(ii) A member, who has completed 10 years service and alse attained the age of 50 years is eligible to

draw pension at reduced rate, after leaving the employment.(iii) .~. R;r<A 'rI ~ ~ 3I'i'rTffi crnu! "'" ~ ~ t mt \ffli'f\'I 3Il1j 3l'R "'" 3fCI1t'I ~

'>fi m. ~ 3itfrTm ~ ~ tff?T t I(iii) A member who has left the service on account of total and permanent disablement. irrespective of

his age and period of service. is eligible for monthly disablement pension.(iv) ~ ~ ~ ~ W1?I-l0:~ 1) ~ lffij?I ""'" ~ I(iv) To claim the Monthly pension, application in Form- 10·0 should be submitted.

3. tff?T 'CIftc:!N 11; 'II'IIIN/Type of benefit eligible:\J1!R 'IG .mm-l 3i&tTa ~ ~ f.rq;ffi't ~ qI') <1ft ~ lff'(I m""tff?T t IA member falling under Item I above is eligible to get the amount towards withdrawl benefit.~ \J1!R 'IG ~o - 1 (q;) ;Wjo ~ ~ ~ ~ ~ 'fflOT t ~ ~ f.!I"1~R!J(1 lRjfcM3li ~ mwnSl,uulq~ ~ ~ f<I'q;(:q lffij?I <IR IHowever, a member falling under item 1(a) above is advised to opt for the Scheme Certificate on account 01 follow-ing advantages. .

0) ~ ~ ~ 1) ~ lff'(I m 1:R \ffli'f\'I $I mn 3lCI1U ~ anTI ~ ~ <1211 ~ ~

"" ~ qI') ~ em Fcl f.!Iljf?l(1 ~ ~ I(i)

(ii)

On taking up employment in another establishment, his earlier service period will be carried forward andclubbing both the spells togehter pension entitlement shall be regulated.~ ~ ~ ~ lff'(I 'I'tl C!R'{11 t 3fIx 58 Cf!! qI') 3Il1j ~ lff'(I m" wl t'I ~ m ;;mft t0) ~ ~ "t1'fuIR ~. lff'(I ~ IIf the member does not take up employement and dies before attaining Ihe age of 58 years. His family willgel family Pension. On his survival. he will get withdrawal benem with weightage as may be prescribed.

(ii)

,


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(iii) lir;;r-n SlIlIulq?l Rl"<I m~ ~ im1 ~ ~ ~ <WI f'lI<Imft -Ii ~ ~ "'I1l't ~(iii) While availing a Scheme Certificate, there is no bar to withdraw the P. F. accumulations by the member .•

4. ~"q:f m ~ 'IloI<:,I'1/Guidance for filling the application:'('til JI;ij ~o ~ -Ii ~ lP'I ~o ~ ~ t)(S.No. given below refers to the one given in the application)

lP'I <10-1 «Ii) ~ ct;~ ~ -Ii ~ 3I"j<lR 3N'11 ''IT'I ~ 31m! -Ii ~SI. No.·' (a) Write your name in CAPITAL letters as given in the service records of your establishment.

("{§) ~ \Jfl ~ 1RJ ~ \iii! ~ ~ ct;~ ~ ~ ~ (~ ~/qftm

~) im1 ~ fcI;m \iW!1 t I(b) To be furnished only when the application is preferred by a person other than the memebr

himself (i.e. Nomineelfamily member)~ <Cr m'I Vf""I filIfe'I ~ ~ ~ I2.The exact date of birth of the member should be given.

3 ~ 7 (Ill; fct<RvIi 't <rl'I< ~ ~qHI$~11 lIT 1!iftrT 't ~ ~ ~ ~ ~ \iW!1. I ~ >fI~~ 't ~ fcI;m \iW!1 ~ I

3 to 7 : • Particulars should be written dearly without any overwriting or cutting. Correction if any, beattested.

8. ~ im1 ~ ~ ~ -Ii ~ \iW!1 t ~ m10~ <Cr ~ ~ "'I1l't <WI t 3tR f.rcmfI qfu;nij ~ tml ~ IThe option is to be gven by the merrber orly ~he has not rendered' 0 years service and eflQiblefor withdrawal benefit

9. ~ tllI'im 3tR tfuR (\ifIq.f ~ ~ <l>fI ~) em~ ~ ~ ~ -Ii ~ \iW!1 ~ IComplete particulars of nominee and family (spouse and all children) should be given without fail.

1O. ~ mI llflI;m -Ii wm ~ ~ "'1TfIrn lIT qftm ct;~ ~ im1 Gf1JT ~ fcmn 1f!IT m ITo be furnished when the claim is preferred by nominee or the family member (s).

11. ~ ~ <N't ~ fcI;m ~ \iii! ~ ~ ~ ~ tml m 3tR \NR lir;;r-n SI'lIuIQ?l ct;~ tR ~ ~f!Icm;q ~ m I ~ ~ tR "ffi'1. "'I1l't t ;:;II lir;;r-n ~Illulq?l ~ ~ ~ ~ ~ f.rcmfI ~ cj; ~tR lir;;r-n jllllulq?l ~ ~ ~ t I)To be completed only when a membef is eligible for withdrawal benefit and opted for It In lieu of scheme Cert~icate(not applicable to those who are entided for Scheme Certificate or opted for Scheme Certificate in lieu of with-drawal benefit.)

12. ~ ~ <t>4'<l1;fJ~ mwn. 1995 ct;me, IIftlIR ~~ ~ ffi t en \HI ftnRvt ~ ~ IIn case, the member is drawing Family PensionlPension under the Employees' PenSion Scheme 1995. the detailsshould be furnished.

3If!Iij ~ ~/Adv.nce Receipt:Gf1JT ~ "IIIl ",filRl1lurq,,/Attestation of claim form:

Gf1JT ~IElI~ul\t \Jfl fll4)iffll ~ ~ ~ ~ ~ ~ ~ 3Rt -Ii fll4)ftIo mThe claim should preferably be attested by the employer under whom the member was last employed.~ fimfI C/i1~Olq~1~ ~ 't 3!tA ~ fllUl<t01 ~ ~ "iI'Rf.I-li ~ t m \HI ~ fiji <rn ~

<m ~ m ~~ i!Il fll"1R1fttl1 ~ 31~C/iI~1]j -Ii ~ ~ ~ ~ ~ ~ ~ ~ <t>lllli'lll i!Il3m ~I~o "IlR ~ I

. If for any reason, the claimant is unable to get the application attested by his ex-employer, he may lorward the claimto the Provident Fund office duly clarifying the position, after getting it attested by anyone of the following authorisedofficials:

0) \Jflh;ct;~~~~emmm~t I(i) Manager of the Bank where the member is holding an account.(ii) fI~ ~ emSlUR/Head of Educational inslitutlon.

(iii) mitQ~n 3l1U<mft1 A GazeHed Ollicer.(iv) \JQ :S14iQli'I/;SIC/iQli'lSub·Post Masler.

(v) Ilftt~(!/The Magistrate

(vi) ~~~WJo;jct;~~~ I(vi) Memeber 01 Central Board of Trustees

Employees's Provident Fund or Regional Committee(vii) 3IUm~/'''HqlR1<t>I/~ / ~;iTt em~(vii) Chairman/Secretary/Member of the MunicipaVDistrictILocal Board(viii) m'I/1fmmI CI>I 3IUm/~;m ~/~ ~(viii) President of the village Union / Panchayat / Member of Parliament / Member of Legislative Assembly.(.x) e);fro ~ ~ 3mj<m im1 31j")~(1 ~ ~ 3l1U<mft(ix) Any othef officer approved by the Regional P. F. Commissioner

5. ~ 3RI ~ IlI'!cal.,/'(Qoe)C/i~UI ~ lI>'It t) ~ fll<t>coll ~ ~ C/illlll'l4 ct; \iI'1tiQq\ ~ ~

~ ~ef0m'!4 >fI ~f'I1R1o t )~M fcI;m vn <llIiOl t I5. For furher guidance/clarifications required, if any the Public Relation Officer in the nearest Provident Fu nd OHioe

(including Provident Fund Inspectorates) may be contacted.







•

~ <Ill<II ('1 <I ct; wWn~For Office Use Only

3ITQ<Ii 'fi 0 .

In ward No..................•..

WlI ~.Serial No ...................•..

~ 'fio 10-l! (<Iloqomo)Form No. 10-C (E.P.S.)

Cf) 4:q loft -q"W{ til G1 '11 , 1995EMPLOYEES PENSION SCHEME, 1995

",4i11;f! ~ 4)\11"11, 1995 cf; ~ iml m f.1"'I~

qRC1111/lOl1\i1"11!>Il'(lolq~ cf; ~ ~ ~ ~ ~ <ITC1l mFORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,

1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE

(m ~ ~~ f.RWf q;) ~)

(Read the instructions before filling up_this form)

1. ("<Il) ~ <PI '!Tll (~ 3!arn "4)Name of the Member(In Block Leiters) : _

("{!I) ~ <PI '!TllName of the claimant (s): _

2.~Date of Birth

3. fQm <PI "'fllIIFalhe(sName _

qfi'J<PI'!TllHusband's Name (lfapplicable) _

4. ~ <PI '!Tll q tfffi ~

~ 3iCI "4 PnMtJ C1 m IName & Address of theEstablishment in which.the member was last employed

5. m 'fi. <1m ~ 'fi.Code No. & Account No.

ern/\30 ala ""~ mRegionlSRO Code-.~~m'fioEslt. Code No.

<:llTC1T 'fi .Alc No.

5A Date of Joining the Estt. _

6. <fen~ <PI <l>R'lT am<fen~~~Reason for leaving service &Date of leaving

7. ~ tfffi (~ 31arn "4)Full Address (In Block t.eners)

~/~~/Sh.lSmt.l1<m. '-' _

~/m::t)/Tfl/Slo, W/o, 0/0 ________ fiR/PIN, _


EPFO

Text Box

Mobile Number :






•8. mn 3IT1l Ptc/)I'I1~1~ cf; ,~ qx mwn (q;) (~)

1I'1lulq~~ m cf; ~ (\~ ~ I (a) (b)Are you willing to accept Scheme Certificate ~ D ""Iti Din lieu of w~hdrawal benefits Yes No

9. rrftc!R i!ll f<ttRuI (tifTI/QRl <1m ~ <1m ~)Particulars of Family (Spouse & Children & Nominee)

rrJl! ~ ~ cf; "ffie! <t.iuName Date of Birth Relationship w~h Member

'11ill f<:t' I cf; ~ i!ll rrJl!Name of the guardian 01 minor

(q;) rrftc!R cf; ~(a) Family members

(~)~(b) Nominee

10. 58 qtf ctt 3IT"g lIT'<! m cf; "iITc:" ~ ctt ~ ~ IR, ~ c:rcn ~ ;-In case of death of member after attaining the age of 58 years without filing the claim ;.

(q;) ~ ctt ~ ctt ~Date of death of the member

~) GI~(m~cf; rrJl!/am ~ " ~ <t.iuName of the Claminant(s)/and relationship w~h the member

11. ~ i!ll lflUI1'! (fi'C/)~a fcI1U cf; ~ ~ cm1lC<fi Tj ~ erR)Mode of remittance (put a tick in the box against the one opted)

«1» "'1G <i. 7 Tj ~ tffi qx ~ m>TO qx GT<f; >M'l~ GR1By postal money order at my cost to the address given against item No.7

~) ~ ~ ~ <flm ~ ~q; (31'j~a ~q;/;SIc/)Q;1) Tj fi<IO ma Tj i:;f'11 "M~*,,~I~~~"If\mlAccount payees cheque sent direct for credit to my SB Nc (Scheduled Bank)Under intimation to me.

D

Dfi<IO ~q; .~ <io/S. B. Account No.

~q; i!ll -;;rq ~ 31effl Tj)Name of the Bank (In block letters)

~ ~ 31em TjYBranch (In block leiters) ;

Full address of the Branch (in block letters)

12. "il<Il 3IT1l q;0 Qo 11)0-95 cf; m:o Q~ lIT'<! "" ~ ~7

Are you availing pension under EPS-95?

~ iI. ffi ~ erRIf so, indicate PPO No .

~ GR1 V{RtBy whom issued .

wnfVra fc\mT UfRIl ~ f<I; f<ttRuI ~ ~ ~ cf; 3I'j"ffi"< ~ ~ ICertified that the particulars are true to the best of my knowledge.

~-iTi!l ;Date .

~ * 51'01ffi 3ImIT (;[11)-gJ~ i!ll 3ilJPl f.'mAISignature or left Hanci Thumbimprecsion of the Member I claimant (s)







3Jfitq ~ ~Advance Stamped Receipt

~ \JiCR (tll) $ ~ '"t'l ~o fcl;<n ~[To be furnished only in case of (b) above)

Q~ f.rfa tllffi $ f.rtrcA ~ e);fu:j ~ f.rra ~/;;q-~ q;rllj(:f!1 $ 1l'lITl ~ ~ ~ iIml ~ij;

tllffi l:f ;:;p:!J &NT ~o (00 -q') ) ~mQ1'<1~1

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 Nc towards the settlement of my Pension Fund Account.

~ \'RQ'i ~ fffiI ~ q;) ~ ~ f.rra ~/1l'lrt'I ~ &NT 'IR1 VfIlPllIThe space should be left blank which shall be filled by Regional Provident Fund Commissioner/OHicer-in-charge)

~ tR ~ $ ~ffi ~ <ii<I tnl!l $ ~ <PI f.'mRSignature & lef1 hand thumb impression of the member on the stamp

As. 1 RevenueSI~

~1fI~ fcl;m vmn ~ fi); ~<'ll llHl ~ fcMuT <ftt ~ ~ ,R<'ll " ~ W'le1 ~ffi ~ ~/~ ~~~ICertified that the particulars of the member given are correct and the member has signed/thumb impressedbefore me.

~ ~ ~ ~ tR ~ ~ $ fcMuT r.t'"1lj<IH ~ :-The details of wages and period of non-contributory service of the member are as under:(l:Iq'3-31:1/7) {c!;otiomo) \ffi 3fc!1t) <PI ~ ~ fvm 3I<I1il ~ 1) ~ ~ f.'m) ""q;ml<fl\;;('1mqem ~ "It! 1TI1 ill)(Form 3A17 (EPSll enclosed for the period for which it was not sent to Employees' Provident Fund Office)

~ 15.11.95 em ~ ('l<'1 ~ + ~ 'Ifffi) ~ 0I'f'll~)Wages (Basic+D.A.) as on 15.11.95 (_applicable)

~ ;mrR ~ f<l~ q;) ~Wages as on the date of exit

tR 3imnfI tl<rt ~ 3lCliUPeriod of non contributory Service

i!1!/tj'ffiYear/Month

~No. of days

Date ..

r.tq)<tOI/~ ~ $ ~ffi

Signature of Employer/Authorised Official

~ qH<liC!1<1 '15 )141.,,4(For the use 01commissioner's office)

~o $ 3!UA/3IGrn"'i'I1lG 'flo 1f'fi~~

(Under Rs .. ........................................... PI. No M.O.lCheque.

~O OO .q ~ 3IGTWfi ~ ~ jWmlPassed for payment for Rs (in words) _ .

1f'fi~ q;<\'i~I'1 (~ ~ ~) f.r<tiRfl ~ qft f.i<R;r m .M. O. Commission (if any) _ net amount to be paid by M. O ..

towards withdrawal benefit.

'flo !BoD.H.

~erq;S. S.

<lo(ijo3ifQoA.AO.

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• •

(~ ~ Sl4)'nst.f)(For use in Cash Section)

$Ii <{o ~ im1 m R;M ~ ~fffict>1 ~q;) 1lTt!T

<{0-10~ 'fG <{o lR ~ <IR ~ t I

Paid by inclusion in cheque No. . 01 vide cash Book (Bank) Account

No. 10 Debit item No .

aq qcloS.S.

,",0 3!fi)0 ~)AC(Gash)

~. ~. 3lTl. ;fro ~. ~ ~ m~fRc1 ~ ~ ;-For issue of S. S. ; IDS Is enclosed

,",0 fRoD.H.

,",0 ~o3floAAO.

,",olfof.io3flO ~)APFC (Ales.)

,. ----------~--------------------------------------------------------

(~ ~~ ~ Sl4)'nd)(For use in Pension Section)

mwn IwIOI4::( ftrn lR f.14::(ol <{o \3~ltId t. q;)

~ q;) ~ ~ 3ft< ~ ~ mwn 11''1IOI4::( f.14::(ol q\ifr .q qfli

i Scheme Certificale bearing the control No issued on and enlered inIhe Scheme CertHicate Control Register.

,",0 fRoD.H.

aqo qclo

S.S.

,",0 ~ 03!fi)0

AAO.

,",olfof.io3flo (q~)APFC (Pension)

.'.

Documents

Download form 19 and 10c epf india