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Form 19 New

This document appears to be a form for an employee to request settlement of their Provident Fund Account. The form collects information such as the employee's name, father's name, employer details, account number, date and reason for leaving service, current address, and preferred method of payment (postal money order or bank transfer). It also includes tables to provide contribution details by month for the current financial year, a declaration of non-employment, and a stamped receipt section for the employee to acknowledge receipt of payment. Employer authentication and payment processing sections are also included at the bottom.

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ashishrajmakkar
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2K views2 pages

Form 19 New

This document appears to be a form for an employee to request settlement of their Provident Fund Account. The form collects information such as the employee's name, father's name, employer details, account number, date and reason for leaving service, current address, and preferred method of payment (postal money order or bank transfer). It also includes tables to provide contribution details by month for the current financial year, a declaration of non-employment, and a stamped receipt section for the employee to acknowledge receipt of payment. Employer authentication and payment processing sections are also included at the bottom.

Uploaded by

ashishrajmakkar
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 ..

PF Code ____________________

E Code _____________

Mobile No
E mail ID

____________________
____________________

Employees Provident Fund Scheme, 1952


Form 19
(Refer to Instructions)
1
Name of the Member (in block letters)
2
Fathers Name (or Husbands Name
in the case of married woman)
3
Name and address of the Factory/
establishment in which the member
was employed
4
Account No.
5
Date of leaving service
6
Reasons for leaving service
7
Full Postal address (in Block letters)

Resignation
Shri/Smt/Kumari
S/o d/o w/o

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

Mode of Remittance

(a)
(b)

By Postal Money Order at my cost


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

(
(

)
)

To the address given against item No. 7


S.B. Account No
Name of the Bank
Branch
Full address of the Branch

(Advance Stamped Receipt furnished below)


Certified that the particulars are true to the best of my knowledge
Date of joining the Establishment __________________________
Date of Birth
__________________________
Contribution for the current financial year
Month
Month

Wages

Contribution
Employee
EPF
FP

Employer
EPF
FP

Period of
Break if any
Total
EPF
FP

Month
Month

Wages

Contribution
Employee
EPF
FP

Employer
EPF
FP

Period of
Break if any
Total
EPF
FP

PF Code _____________________________
(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 or 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 ________________________________________ only) 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.
Affix 1/Rupee
Revenue
Stamp

The space should be left blank which shall be filled


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

Signature or Left/Right hand thumb impression of the member


(For the use of Commissioners Office)
A/c. Settled in Part/Full Entered in F.21-A/24/219 & Withdrawal register.
Clerk
Section Supervisor
P.I.No.
MO/Cheque
Account No.______________ Section__________ Passed for Payment for Rs. ___________
(In words ________________________)
M.O Commissioner (if any)
AOC./ APFC.
Net Amount to be paid by MO Rs.
Date

(For use in Cash Section)


Paid by inclusion in Cheque No. __________________________________ dated ___________
vide Cash Book (Bank) Account No. 3 Debit Item No. __________________________________

HC

AC / RC
Remarks

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