Mobile No :

Emp ID
Inward. No. __________________ For Office Use Only

EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952

FORM 19
FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 FOR CLAIMING THE EMPLOYEES' PROVIDENT FUND DUES [Para 72(5)] REFER TO INSTRUCTIONS 1 Name in full (Block Letters) 2 Parent / Spouse Name 3 Name and address of the Factory /

Establishment In which member was last employed.

the

Infosys BPO Ltd Plot No 26/3, 26/4 and 26/6 Electronics City, Hosur Road Bangalore 560 100

4 Code No. & Account No. 5 Date of Leaving Service 6 Reason for leaving service 7 Full Postal Address (in Block Letters) Shri / Smt./ Kumari S/o. W/o. D/o.

No.

KN / BN / 34177 /

Resigned

8 MODE OF REMITTANCE

M.O.
a. By postal money order at my cost if amount
payable exceeds Rs. 500/- (if the amount is less than Rs. 500/- M.O. commission will be borne by PF Office)

PIN Put a tick against the one opted Cheque

to the address given in item No.7

b. By account payee cheque sent direct for S. B. A/c. No. cedit to my SB A/c (any Scheduled Bank / Post Office / Co-operative Bank) under intimation to me (Advanced Stamped Name of the Bank: receipt furnished below)

Branch : Full Address of the Bank

c. By deposit in Payee's name (the whole or part of the amount) in the form of Anneuty / Term deposit in any Nationalised Bank.
Note to the Employer : 1. Please advise the Members to furnish correct Address / Information 2. Please complete the Form 3A in Para - 3 & 4, with full particulars, in respect of the years for which Annual Accounts have not been received (Add more sheets if necessary) 3. All corrections / alterations should be attested. 4. If the payment exceeda more than Rs.2000/- above payment will not be made through M.O Please furnish S/B A/C. No. duly opened in any Nationalised Bank/Schedule Bank/Co-Op Bank with full Postal Address

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

X
Date : Date of Joining the establishment Date of Birth / Age Date of leaving Service Signature / Left hand thumb impression of the member _______________________________ _______________________________ _______________________________

Certified that the particulars of the member given are correct and the member has signed /thumb impressed before me. For Infosys BPO LTD

Date :

Sign of Employer / Authorised Official with Rubber Stamp

ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b/c) above) Received a sum of Rs. _____________________ (Rupees ________________________________ _______________________________________ Only) From the Regional Provident Fund Commissioner / Officer-in-charge of Sub Regional 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 Employees Provident Fund Office. Affix Re1/Revenue Stamp

Signature / Left hand thumb impression of the member on the Revenue stamp FOR THE USE OF COMMISSIONER'S OFFICE Account settled in part / Full Entered in F.21 A/24/2/9 and withdrawal Register Clerk Section Supervisor

(Under Rs. _________________________________________________________________________only) P.I_____________________M.O./ Cheque ________________________ A/c. N.KN / BN.______________ Section______________________ Passed for Payment for Rs. __________________________ (in words) Rupees _________________________________________________________________________ only) M.O. Commission if any ___________________________________________ Date _____________ Net Amount to be paid by M.O.__________________________ Date: FOR USE IN CASH SECTION Paid by inclusion in Cheque No. ________________ dated _____________ vide Cash Book (Bank) Account No. 3 debit item No. C.W. S.S. AAO A.P.F.C. / R.P.F.C. A.A. O. / A.P.F.C.

REMARKS Acknowledgement received on ________________________ Verified on _________________________

FORM 3-A REVISED For the Year ______________ Account No: KN/ BN __________________________ 2. Name : __________________________________ Month WORKER'S SHARE Amount of Between 10% EPF Wages 2 3 EMPLOYER'S SHARE Fund E.P.F. Difference between Pension Fund 12% / 10% and 8 1/3% if any Contribution 8 1/3% 4 5 Ref. of Advances 6

1 March paid in April May June July August September October November December January February Feb paid in March Supplimentar y TOTAL

Certified that the total amount of contribution indicated in this card has already been remitted in full For INFOSYS BPO LTD

Date : For Office use only Month Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar TOTAL Interest : Dealing Clerk Note : Section Supervisor Opening Balance (Both shares)

Signature of Employer with offical Seal Contributions Shares) (Both Withdrawal (Both Shares)

AAO / APFC Interest = IBB X 12 (Rate of Interest for 200 12 X 100 -200

FORM No. 10 - C

(E.P.S.)
Inward No:

EMPLOYEE'S PENSION SCHEME - 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Read the instruction before filling of this form) 1 (a) Name of the member (in Block Letters) (b) Name of the claimant(s) 2 Date of Birth

3 (a) Father's Name (b) Husband's Name (if applicable) 4 Name and address of the Establishment in which, the member was last employed

Infosys BPO Ltd Plot No 26/3, 26/4 and 26/6 Electronics City, Hosur Road Bangalore 560 100

5 Code No. & Account No.

RO/SRO Code Estt Code No.

A/c No.

KN / BN / 34177 /
6 Reasons for leaving Services

& Date of Leaving

7 Full Postal Address (in Block Letters) Sri / Smt. / Kum. S/o. / D/o. / H/o. / W/o.

PIN : 8 Are you willing to accept Scheme Certificate in lieu of Withdrawal Benefits ? (a) Yes (b) No

9 Particulars of Family(Spouse,children or Nominee Name (a) Family member/(s)

Date of Birth

Relationship Name of the with the member guardian of minor

(b) Nominee

10 Incase of death of the member after the age of 58 years without filing the claim :

(a) Date of death of the member (b) Name of the claimant(s) and relationship with the member 11 MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ON OPTED) (a)By postal money order at my cost to the address given against column No.7 (b) Account payee cheque sent direct for credit to my S.B.A/c (scheduled bank) under Intimation to me. S.B A/C No Name of the bank(in block letters) Branch(in block letters) Full postal address of the Branch (in block letters)

PIN 12 Are you availing pension under EPS-1995 if so,indicate PPO No

by whom issued

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

X
Date Signature/Left hand thumb impression of the Member/cliamant(s) ADVANCED STAMPED RECEIPT (To be furnished only in case of 11(b) above)

only) Received a sum of Rs _____________________ (Rupees______________________________________ from the Regional PF Commissioner/officer-in-Charge of Sub-regional Office, by depositing in savings Bank A/c towards the settlement of my Pension Fund account.

The space should be left blank which shall be filled by this office.

Affix Rs 1 Revenue stamp

Signature/left hand thumb impression of the member on the

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me. The details of wages and period of non-contributory service of the member are furnished under (Form 3A/7(EPS) enclosed for the period for which was not sent to Employees' Provident Fund Office).

Date of joining Wages (Basic+D.A) as on 15/11/95 (if applicable) Wages on the date of exit Y Period of non-contributory service M D

Date

Signature of Employer/Authorised Offical with Rubber stamp

(FOR THE USE IN OF COMMISSIONER'S OFFICE (Under Rs ____________________________ P.I. No_____________________ M.O/cheque __________________ passed for payment for Rs_____________ (Rupees_____________________________________________ only) M.O Commission(if any)Rs______________ net amount to be paid by M.O _______________ towards withdrawl benefit

D.A

S.S (FOR USE IN CASH SECTION)

A.AO

Paid by inclusion in cheque no_______________________________date _______________vide Cash Book Account no.10 Debit Item No. __________________

D.A For Issue of S.S. ; IDS is enclosed.

S .S

AC(Cash)

D.A

S.S ( FOR USE IN PENSION SECTION)

APFC(A/cs)

Scheme Certificate bearing the control no Scheme Certificate Control Register.

issued on issued

and entered in the

D.A

S.S

APFC(Pension)

(EMPLOYEES' PROVIDENT FUND ORGANISATION Regional office, Karnatak, Bangalore.

MANDATE FORM to be furnished along with all claim / Advance applications) Form No. E. 5 Appendix - VIII

ELECTRONIC CLEARING SERVICE (CREDIT CLEARING) MANDATE FORM INVERSTOR - CUSTOMER OPTION TO RECEIVE PAYMENTS THROUGH CREDIT CLEARING MECHANISM MEMBER'S NAME 1 (CUSTOMER'S NAME) 2 PARTICULATS OF BANK ACCOUNT

A.

BANK NAME

B. C.

BRANCH NAME 9 - DIGIT CODE NUMBER OF THE BANK AND BRANCH APPEARING ON THE MICR CHEQUE ISSUED BY THE BANK

(PLEASE ATTACH THE PHOTO COPY OF A CHEQUE OR A BLANC CANCELED CHEQUE ISSUED BY YOUR BANK FOR VERIFYING THE ACCURACY OF THE CODE NO. OR GET THE CERTIFICATE FROM THE BANK IN THE FORM FURNISHED BELOW) ACCOUNT TYPE WITH CODE 10/11/13 LEDGER FOLIO NO. (IF APPEARING ON THE CHEQUE BOOK) S.B.A/c. No.(AS APPEARING ON THE CHEQUE BOOK)

D.

E.

F.

3 DATE OF EFFECT I HEREBY DECLARE THAT THE PARTICULARS GIVEN ABOVE ARE CORRECXT AND COMPLETE IF THE TRANSACTION IS DELAYED OR NOT EFFECTED AT ALL FOR REASONS OF INCOMPLETE OR INCORRECT INFORMATION, I WOULD NOT HOLD USER INSTITUTION RESPONSIBLE. I HAVE READ THE OPTION LETTER AND AGREE TO DISCHARGE THE RESPONSIBLE EXECTED OF ME AS A PARTICIPANT UNDER THE SCHEME.

X
DATE (..) SIGNATURE OF THE CUSTOMER / MEMBER CERTIFICATE OF CUSTOMER'S BANK CERTIFIED THAT THE PARTICULARS FURNISHED ABOVE ARE CORRECT AS PER OUR RECORDS

BANK STAMP DATE SIGNATURE OF THE AUTHORISED OFFICIAL OF THE BANK

Note : In lieu of the Bank Certificate to be obtained as above, customer/ member can attach a blank cancelled cheque or a pot copy thereof