ONLINE TRANSFER CLAIM FORM [FORM 13 (REVISED)] (Tracking ID 999315051501160007155 ) (Submitted through the member log-in 3494618) Claim Date : 16-01-2015 EMPLOYEES’ PROVIDENT FUND SCHEME, 1952 (PARA 57) (This form has been printed on the basis of Online Transfer Claim Form filed up by the member for submission to the employer) To, The Regional P.F. Commissioner, PUNE MH Mit sir, | request that my Provident Fund balance along with my Pension Service Details may please be transferred to my present account under intimation to me. My details are as under: PART A: PERSONAL INFORMATION 1. Name ‘SUHAS VILAS DOLSE 2. Mobile Number 9028640234 3, E-mallid ‘suhasdolse@gmail.com 4. Bank Account Number +: 07941140107013, 5. Bank IFSC HOFC0000794 PART B: DETAILS OF PREVIOUS ACCOUNT (WHICH IS TO BE TRANSFERRED) 1. P.F. Account No. (with EPFO. : PUPUNO3012060000000008 office) 2. Name of the Establishment: BROSE INDIA AUTOMOTIVE SYSTEMS PVT LTD. 3. Address of the Establishment : 202,PANCHSHIL TECH PARK, S.NO.19/20, HINJEWADI PUNE MH 411057 4. PF AIC No. held by PUNE 5, Name of the Trust Not Applicable 6. PFAICNo. in Trust Not Applicable 7. Member Name ‘SUHAS DOLSE 8. Date of Birth +: 22-10-1984 8. Father's/Spouse Name: Vilas 10, Relationship : FATHER 11, Date of joining 14-03-2011 12. Date of leaving + 90-06-2014PART C: DETAILS OF PRESENT ACCOUNT 1. P.F. Acoount No.(with EPFO. : PUPUNO3081660000000204 office) Name ofthe Establishment _: KNORR-BREMSE TECHNOLOGY CENTRE INDIA PVT.LTD. ‘Adress of the Establishment : $ NO 276,VILLAGE-MAAN, HINJEWADI PHASE-|I, ‘TAL-MULSHI,PUNE PUNE 601 MH 411057 4. PF AIC No, held by = PUNE 5. Name of the Trust Not Applicable 6. PFAC No. in Trust + Not Applicable 7. Bank Account Number of : Not Applicable Trust 8. IFS Code of the Bank Branch : Not Applicable of Trust where account is maintained 8. Member's Name ‘Mr SUHAS VILAS DOLSE 10, Fathers/Spouse Name _—_: RITA SUHAS DOLSE 11. Relationship : SPOUSE 12, Date of joining + 01-07-2014 |, Certify that all the information given above are true to the best of my knowledge and | have ‘ensured the correctness of my present and previous account numbers, Signature of the member [275 | ‘Note: Member should take a printout of this form and a signed copy of the same should be ‘submitted to the Previous Establishment i.e. BROSE INDIA AUTOMOTIVE SYSTEMS PVT LTD.