Form to be printed back to back.
Enclose latest bank statement if the
Employee Code-
Cheque leaf does not have your name printed.
Email ID:-
Regn. No... Mobile No.
Employees' Provident Fund Scheme, 1952
Form-19 Email ID
(Refer to instruction) Furnish your Name Legibly in capital letters. Mention the name as per cheque leaf in case there
is name mismatch between PF Record & Bank Account.
1. Name of the members in Block Letters.
Fil Mobile No.
2. Father's Name or (husband's Name in the case of married woman) Furnish Your Fathers / Husbands name legibly (as
applicable) in capital letters. This is a mandatory field.
3. Name & Address of the Factory/Establishment
in which the member was employed. Furnish the Name and Full address of the Establishment
4. Account No.:.. Furnish the Provident Fund Account Number as allotted to the Member
5. Date of leaving service Correct Date of Leaving to be filled in.
6. Reason for leaving service
Indicate Only RESIGNATION as reason for leaving
7. Full Postal Address (in Block Address) Shri/Smt./Kum...
S/O/W/O/D/O...
Full Postal Address In India to be filled in Block Letters.
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...
It is Mandatory to get payment directly into account, Full address of Bank Branch along with Name and Bank A/c. no. should be
mentioned. The employee must be the sole beneficiary of the Bank Account. Joint account with spouse is also accepted provided
marriage certificate is enclosed as proof. NRI / NRE BANK account are not accepted. NRO Account is accepted.
Certified that the particulars are true to best of my
knowledge. Correct DOJ to be filled in. IF you had a PF Account in MS PF Trust before MARCH
2007 than mention your DOJ as 01/03/2007.
Date of joining of Establishment...
Mention your Date of Birth
Date of Birth ...
Contribution for the Current Financial Year.
Period of Period of break
Month Contribution break if any Month Contribution if any
Employee Employers Total Employee Employers Total
Month Wages Month Wages
EPF FP EPF FP EPF FP EPF FP EPF FP EPF FP
To be filled by the Employer
( 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.
Member to sign in the application here.
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.
Member to sign in the application here.
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 Affix 1/- Rupee
in by Regional Provident Fund Commissioner/Officer Revenue
in-Charge of S.A.O. Stamp
Mem Affix RS 1/- revenue stamp and sign across it. For BANGALORE employees of MS GTSC,
MSR, MSR, MS IDC affixing Revenue stamp is NOT mandatory. Simply sign across here.
Signature or Left / 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. ----------------------------- Sectionpassed for payment for Rs.-------------------
in words)-------------------------------------------------------------
------------------------------------------------------------------ M.O.
NetCommissionAmount to(if beany)paidAOC/APFCbyM.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
