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

http://epf-india.co.in/epf-balance/

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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Write your Mobile Number on top of form to get SMS alerts.

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(Supplied free of cost)

4)\jf~1,1995

EMPLOYEES' PENSION SCHEME, 1995

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Form 10-C (E.P.S.)
PtC6I~ qR<'II~/m\jFlI

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311~C;"1>Jq'5f

Form for claiming withdrawal benefit/scheme certificate

f.tcflT/INSTURCTIONS
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Who Can apply ?

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~
~
1971/<i>4illfi ~~.
1995~ ~
~
R;r<A
A Member of the Employees' Family Pension Scheme. 1971/Employees' Pension Scheme. 1995.
(q;) 10 Cf!! mI
f.!Iq)"1'1
t

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2.

em ~ ~

(a)

Who has left the employment before completion of 10 years service.

(~)
(b)

10 Cf!! mI
1) ~ II ~
<I> fIR ~
58 Cf!! mI 3Il1j
'i" "" '' I
Who has attained the age of 58 years before completion of 1Oyears service - whether in servicelleft the service

('1)

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em m'<f ~ SlIT t <II ~ ~

em

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50 ~

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3Ift)q; IR'\j 58 <f!i <Gt l51l <Gt 3Il1j
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A member. who has completed 10 years service on the date of his leaving the service and has not attained the age
of 50 years on the date of filing this application orhas attained the age of 50 years on the date of filing this application
or 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')
(~'i!iW t) ~ 10Cf!! mI
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Note-I:

To determine the period of 10 years service rendered from 1.3.1971 to 15.11.1995 (if any). shall
also be taken.

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10

<ft t 3fIx 58 1f'i qI') ~

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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.
~
R;r<A 10 <f!i qI') "'" ~ 1!R <ft ?1m 50 Cf!! (I\) 3Il1j '>fi ~ 1!R <ft t ~
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Note-II

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(i)

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tff?T

(ii)

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(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)

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(iii)

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(iv)

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.
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(iv)

To claim the Monthly pension, application in Form- 100 should be submitted.

'CIftc:!N 11; 'II'IIIN/Type of benefit eligible:

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A member falling under Item I above is eligible to get the amount towards withdrawl benefit.
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However, a member falling under item 1(a) above is advised to opt for the Scheme Certificate on account 01 following advantages.
.
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(i)
(ii)

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Fcl f.!Iljf?l(1 ~
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On taking up employment in another establishment, his earlier service period will be carried forward and
clubbing both the spells togehter pension entitlement shall be regulated.
~
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lff'(I 'I'tl C!R'{11
3fIx 58 Cf!! qI') 3Il1j ~ lff'(I
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(ii)

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If the member does not take up employement and dies before attaining Ihe age of 58 years. His family will
gel family Pension. On his survival. he will get withdrawal benem with weightage as may be prescribed.

http://epf-india.co.in/epf-balance/

4.

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While availing a Scheme Certificate, there is no bar to withdraw the P. F. accumulations by the member .

m~

'IloI<:,I'1/Guidance

for filling

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(iii)
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(iii)

the application:

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(S.No. given below refers to the one given in the application)

lP'I <10-1

Ii)

SI. No.'

(a)

ct; ~ ~
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Write your name in CAPITAL letters as given in the service records of your establishment.

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(b)

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To be furnished only when the application is preferred by a person other than the memebr
himself (i.e. Nomineelfamily member)

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2.

filIfe'I ~ ~

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The exact date of birth of the member should be given.

3 ~ 7

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Particulars should be written dearly without any overwriting
attested.

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3 to 7 :

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The option is to be gven by the merrber orly ~ he has not rendered' 0 years service and eflQiblefor withdrawal benefit
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8. ~
9.

or cutting. Correction if any, be

Complete particulars of nominee and family (spouse and all children) should be given without fail.

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To be furnished when the claim is preferred by nominee or the family member (s).
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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 withdrawal benefit.)

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1995 ct;

me, IIftlIR ~~

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en \HI ftnRvt

In case, the member is drawing Family PensionlPension under the Employees' PenSion Scheme 1995. the details
should be furnished.

3If!Iij ~
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~/Adv.nce

Receipt:

"IIIl ",filRl1lurq,,/Attestation

of claim form:

~ ~
~
~
~
~
~
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The claim should preferably be attested by the employer under whom the member was last employed.

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

0)

\Jflh;ct;~~~~emmm~t

(i)

Manager of the Bank where the member is holding an account.

(ii)

fI~

em SlUR/Head of Educational inslitutlon.

3l1U<mft1

A GazeHed Ollicer.

(iii)

mitQ~n

(iv)

\JQ :S14iQli'I/;SIC/iQli'lSubPost Masler.

(v)

Ilftt~(!/The

(vi)

~~~WJo;jct;~~~

(vi)

Memeber 01 Central Board of Trustees

Employees's Provident Fund or Regional Committee

(vii)
(vii)

3IUm~/'''HqlR1<t>I/~
Chairman/Secretary/Member

Magistrate

/ ~;iTt
em~
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)
(ix)
5.

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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.

~
5.

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~
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~
3l1U<mft
Any othef officer approved by the Regional P. F. Commissioner

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Mobile Number :

<Ill <II ('1 <I

ct; wWn~

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Serial No .....................

For Office Use Only

3ITQ<Ii 'fi 0

'fio 10-l! (<Iloqomo)

Form No. 10-C (E.P.S.)

In ward No....................

Cf)

4:q loft -q"W{ til G1'11 ,

1995

EMPLOYEES PENSION SCHEME, 1995

4)\11"11, 1995 cf; ~

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FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,

1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME

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(Read the instructions

1.

<PI '!Tll (~

("<Il) ~

3!arn

f.RWf

CERTIFICATE

q;) ~)

before filling up_this form)

"4)

Name of the Member

(In Block Leiters) :

("{!I) ~

<PI '!Tll

Name of the claimant (s):

2.~
Date of Birth

3.

fQm <PI "'fllIIFalhe(sName

qfi'J<PI'!Tll
Husband's Name (lfapplicable)
4.

<PI '!Tll q tfffi ~

3iCI "4 PnMtJ C1 m

Name & Address of the

Establishment in which.
the member was last employed
5.

m 'fi. <1m ~

ern/\30 ala ""~ m

'fi.
Code No. & Account No.

RegionlSRO Code

-.

5A Date of Joining the Estt.

6.

<fen~
<fen~~~

<PI <l>R'lT

~~m'fio

<:llTC1T 'fi .

Eslt. Code No.

Alc No.

am

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,

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Particulars of Family (Spouse & Children & Nominee)

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Date of Birth

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Yes

rrftc!R

Name

(b)

(a)

Are you willing to accept Scheme Certificate

in lieu of w~hdrawal benefits

9.

(~)

(q;)

cf; "ffie! <t.iu

No

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cf; ~

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Name of the guardian 01 minor

Relationship w~h Member

(q;) rrftc!R cf; ~

(a)

Family members

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(b) Nominee
10. 58 qtf

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In case of death of member after attaining the age of 58 years without filing the claim ;.
(q;)

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Date of death of the member

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Name of the Claminant(s)/and

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relationship w~h the member

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Mode of remittance (put a tick in the box against the one opted)

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qx ~

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GR1

By postal money order at my cost to the address given against item No.7

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Account payees cheque sent direct for credit to my SB
Under intimation to me.
fi<IO ~q; .~

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B. Account No.

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Nc (Scheduled Bank)

Tj)

Name of the Bank (In block letters)

31em

TjYBranch (In block leiters)

Full address of the Branch (in block letters)

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Are you availing pension under EPS-95?

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PPO No

If so, indicate

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Certified that the particulars are true to the best of my knowledge.

GR1 V{Rt

By whom issued

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51'01ffi 3ImIT (;[11)

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Date

f.'mAI

Signature or left Hanci Thumb

imprecsion of the Member I claimant (s)

http://epf-india.co.in/epf-balance/

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Advance Stamped Receipt

\JiCR (tll) $ ~
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[To be furnished only in case of (b) above)

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$ 1l'lITl ~

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Received a sum of Rs

(Rupees

Provident Fund Commissioner/Officer-in-charge

) only from Regional

of Sub-Regional Office

by deposit in my savings

Bank Nc towards the settlement of my Pension Fund Account.

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The space should be left blank which shall be filled by Regional Provident Fund Commissioner/OHicer-in-charge)

$ ~ffi

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<ii<I tnl!l $ ~

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Signature & lef1 hand thumb impression of the member on the stamp
As. 1 Revenue
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Certified that the particulars of the member given are correct and the member has signed/thumb impressed
before me.

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$ fcMuT r.t'"1lj<IH ~ :-

The details of wages and period of non-contributory service of the member are as under:

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(l:Iq'3-31:1/7)

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(Form 3A17 (EPSll enclosed for the period for which it was not sent to Employees' Provident Fund Office)

15.11.95

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Wages (Basic+D.A.) as on 15.11.95 (_ applicable)

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Wages as on the date of exit

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Period of non contributory Service

i!1!/tj'ffi

~
No. of days

Year/Month

r.tq)<tOI/~
Date

Signature of Employer/Authorised

..

qH<liC!1<1

(For the use

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(Under Rs

office)

$ 3!UA/3IGrn"'i'I1lG

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M.O.lCheque.

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Passed for payment for Rs

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(~

M. O. Commission (if any)

Official

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01 commissioner's

........................................... PI. No

..

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$ ~ffi

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_

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net amount to be paid by M. O

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S. S.

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towards withdrawal benefit.

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(For use in Cash Section)

$Ii <{o

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Paid by inclusion in cheque No.

No. 10 Debit item No

aq

;fro ~.

01

vide cash Book (Bank) Account

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For issue of S. S. ; IDS Is enclosed

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APFC (Ales.)

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

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~ Sl4)'nd)

(For use in Pension Section)

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Scheme Certificale bearing the control No

Ihe Scheme CertHicate Control Register.

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APFC (Pension)

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