Employee ID ……………………
Mobile No ……………...............
E-mail ID of employee……………………
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)
1 Name of the Member (in block letters) :
2 Father’s Name (or Husband’s Name :
in the case of married woman)
3. Name and address of the Factory/ : Eureka Forbes Limited,
Establishment in which the member B1/B2 701, Marathon Innova, Marathon Next Gen,
was last employed Off G K Marg, Lower Parel, Mumbai - 400013
4 (a) PF Account No. : WBPRB0007898000 (fill in the number)
(b) UAN (if resigned after 1.7.2014) :
5. PAN (Permanent account number) :
6. Date of leaving service :
7. Reasons for leaving service : Resignation
(Kindly see the notes at the end)
8. Full Postal address (in Block letters) : Shri/Smt./Kumari ____________________________
S/o d/o w/o ___________________________________________________________________
__________________________________________________________Pin________________
Tel:______________________Email:______________________________________________
9 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
(payable upto Rs. 2,000/- only) [ ]
(b) by account payee cheque sent [ ] S.B. Account No. ______________________________
for credit to my account in the Name of the Bank ______________________________
Scheduled Bank/or any post office Branch: ______________________________________
or any Co-operative Branch: Bank ____________________________________________
including Urban Co-operative Bank. Full address of the Branch: ______________________
____________________________________________
____________________________________________
(All the above fields from serial no. 1 to 9 are mandatory)
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date of joining the Establishment: _______________________________ Date of Birth ______________________
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 hand thumb
impression of the member
Signature of the employer or authorized official
Date ________________________
Designation & Seal ___________
In case, however, the members are physically handicapped and cannot affix left thumb impression, the thumb and finger impression of the
right hand failing which toe impression may be obtained.
Note : In the case of submission of application for settlement under clause (e) of sub-paragraph (I) and in clause (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 un-employed in an set. to which the Act applies.
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1
Declaration of Non-employment
I declare that I have not been employed in any factory/establishment to which the Act applies for continuous period of not
less than 2 months immediately preceding the date of my application for final withdrawal of may provident fund money.
Date: Signature or left/right thumb impression of the member
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ADVANCE STAMPED RECEIPT
(To be furnished only in case of 8(b), (c) & (d) above)
Received a sum of *Rs ______________________________ Rupees _____________________________________ only ) from Regional
Provident Fund Commissioner/ Officer-in-charge of Sub-Regional Office/Sub-Accounts Office
__________________________________________ . By deposit in my saving 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.R.O./S.A.O.
Signature or Left hand thumb impression of the member
For the use of Commissioner’s Office
A/c. Settled in Part/Full Entered in F.21-A/24/2/9 (Revised) & Withdrawal register
Clerk S.S.
(Under Rupees________________________) Account No.__________
P.I.No._______________________________
Nature of benefit______
Section___________ MO/Cheque________________
Passed for Payment for Rs.______
(in words) (Rupees___________________________)
Money order Commissioner (if any)
A.A.O./A.P.F.C.
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. __________________________________
S.S. AAO/APFC RPFC
Remarks
Acknowledgement received on _______________________
Verified on __________________________________
NOTES:
Kindly note the circumstances in which a member can withdraw his PF accumulation and documents to be
enclosed along with Form No 19:
A member can withdraw his PF accumulation when he
a) is retiring from service after attaining the age of 58years : no document
b) is retiring on account of permanent and total incapacity for work in Industry due to bodily or mental
infirmity : A certificate is required by a Registered Medical practitioner or the Medical Officer,
should be enclosed
c) is migrating from India for permanent settlement abroad : Migration certificate
d) is going abroad for some employment : Copy of Visa & passport
e) has not been employed in any factory to which the scheme applies for a continuous period of two
months immediately preceding the date of application : A declaration of non-employment to be
attached
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