Mobile: 9611786747 Mobile: 9611786747 Mobile: 9611786747 Mobile: 9611786747

Karunakaran Y N Karunakaran Y N Karunakaran Y N Karunakaran Y N

Narayana Y Narayana Y Narayana Y Narayana Y
Personal Purpose Personal Purpose Personal Purpose Personal Purpose
4. Account No.
5. Date of leaving service
6. Reason for leaving service
Regn. No.
in the case of married woman)
1-Feb-2012 1-Feb-2012 1-Feb-2012 1-Feb-2012
in which, the member was last employed
Shri/Smt/Kumari
S/o, W/o, D/o
Karunakaran Y N Karunakaran Y N Karunakaran Y N Karunakaran Y N
Narayana Y Narayana Y Narayana Y Narayana Y
Employees' Provident Fund Scheme, 1952 Employees' Provident Fund Scheme, 1952 Employees' Provident Fund Scheme, 1952 Employees' Provident Fund Scheme, 1952
Form - 19 Form - 19 Form - 19 Form - 19
1. Name of the member in Block Letters.
2. Father's Name or (husband's name
3. Name & Address of the Establishment
7. Full Postal Address (In Block Letters)
)
)
640560000000 640560000000 640560000000 640560000000
STATE BANK OF MYSORE STATE BANK OF MYSORE STATE BANK OF MYSORE STATE BANK OF MYSORE
BANASWADI BANASWADI BANASWADI BANASWADI
KR ROAD, KR ROAD, KR ROAD, KR ROAD,
BANGALORE - 24 BANGALORE - 24 BANGALORE - 24 BANGALORE - 24
Valayamadevi, Cuddalore Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423 Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423 Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423 Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423
Direct for credit to my S.B
Date of Birth
Name of the Bank
A/c (Scheduled Bank/P.O)
under intimation to me
(a) By Postal Money Order at my Cost (
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IL
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IL
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Full Address
Certified that the particulars are true to the best of my knowledge
S/o, W/o, D/o
To the address given against item No. 7
Put a tick ( ) in the box against the one opted
Narayana Y Narayana Y Narayana Y Narayana Y
# 12, ABC [Vill], BSSS [Po] UUIII [Mandal] # 12, ABC [Vill], BSSS [Po] UUIII [Mandal] # 12, ABC [Vill], BSSS [Po] UUIII [Mandal] # 12, ABC [Vill], BSSS [Po] UUIII [Mandal]
8. Mode of remittance
(b) By account payee cheque sent (
(Advance Stamped Receipt furnished) (Advance Stamped Receipt furnished) (Advance Stamped Receipt furnished) (Advance Stamped Receipt furnished)
S.B. Account No.
Branch
Date of joining of Establishment
Contribution for the current Financial Year
1-Oct-2011 1-Oct-2011 1-Oct-2011 1-Oct-2011
5-Aug-1992 5-Aug-1992 5-Aug-1992 5-Aug-1992
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Designation & Seal
The Applicant has signed/Thumb impressed before me.
ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above) ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above) ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above) ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above)
remain unemplyed in an establishment to which the Act applies.
Signature or left thumb impression of the member
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
Declaration of non-employment
Note:- In the case of submission of application for settlrmrnt under clause (s) of sub-paragraph (i) and in
Date: 02-04-2012 02-04-2012 02-04-2012 02-04-2012 Signature or left thumb impression of the member
(information to be furnished by the Employer if the Claim Form is attested by the Employer) (information to be furnished by the Employer if the Claim Form is attested by the Employer) (information to be furnished by the Employer if the Claim Form is attested by the Employer) (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.
Received a sum of Rs (Rupees from
Date: 02-04-2012 02-04-2012 02-04-2012 02-04-2012


Clerk Section Supervisor
HC AC/RC
(For the use in Cash Section) (For the use in Cash Section) (For the use in Cash Section) (For the use in Cash Section)
P.I.No M.O./Cheque
Account No. Section. Passed for payment Rs.
in by Regional Provident Fund Commissioner/Officer
The space should be left blank which shall be filled
in-charge of S.A.O
Signature or left thumb impression of the member
(in words).
M.O Commission (if any) AOC/APFC..
(For the use of Commissioner's Office) (For the use of Commissioner's Office) (For the use of Commissioner's Office) (For the use of Commissioner's Office)
Revenue
Stamp
Net amount to be paid by M.O... Date
Rs.1/-
Paid by inclusion in cheque No... Date
vide Cash Book (Bank) Account No.3 Debit Item No..
A/C Settled in part/Full Entered in F.21-A/24/219 & withdrawl register
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.