Emp No

Mobile no :

Reg. No.____________

E-mail Id :

Employees Provident Funds Scheme, 1952

Form 19
(Refer to instruction)
1
Name of the member in
BLOCK LETTERS
2

Fathers Name or
(Husbands Name in case of
married woman)
Name & Address of the Factory /
Establishment in which the member
was employed
PF Account No.

5
6

__________________________________________________

___________________________________________

Date of Leaving Service

Reason for Leaving Service

__________________________________________________

__________________________________________________
RESIGNATION_____________________________________

Full Postal Address (in

BLOCK LETTERS)

SHRI / SMT / KUM ___________________________________

S/o / W/o / D/o

___________________________________

__________________________________________________
___________________________ PIN ___________________

Mode of remittance

By Postal Money Order at my Cost

By account payee cheque

sent directly for credit to my
Saving Bank Account
(Scheduled Bank / Post
Office) under intimation to
me

Put a tick (
) in the box against the one opted
( ) To the address given against item No. 7
(

) Saving Bank Account No. ___________________________

Name of the Bank _____________________________________

Branch ______________________________________________
Full address of the branch _______________________________
_____________________________________________________
________________________MICR CODE ___________________
IFSC CODE ____________________________________________

(Advance Stamped Receipt Furnished)

Certified that the particulars are true to the best of my knowledge.
Date of Joining the Establishment

__________________________________________________
__________________________________________________

Date of Birth

Contribution for Current Financial Year

Month
Month

Wages

Employee
EPF
EPS

Contribution

Period of
Break if any

Employers
EPF
EPS

Total
EPF
EPS

Month
Month

Wages

Contribution
Employee
EPF EPS

FORM 3A ENCLOSED

Employers
EPF
EPS

Period of
Break if
any
Total
EPF EPS

(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

Date:

Signature or Left / Right hand thumb impression of

the member

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 subparagraph (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.

Signature or Left / Right hand thumb impression of

the member

Date:

ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above)

Received a sum of Rs. ____________ (Rupees ______________________________________) 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
Ticket

Signature or Left / Right hand thumb impression

of the member

(For the use of Commissioner's Office)

A/C Settled in part/Full Entered in F. 21-A/24/219 & withdrawal register.
Clerk

Section Supervisor

P.I.No._________________________________________ M.O./Cheque _____________________________

Account No. ____________________ Section _______________ passed for payment for Rs._____________
(in words) _______________________________________________________________________________
M.O. Commission (if any) AOC / APFC ________________________________________________________
Net Amount to be paid by M.O. _____________________________ Date ___________________________
(For use in Cash Section)
Paid by inclusion in Cheque No. ____________________ date ____________________________________
vide Cash Book (Bank) Account No.3 Debit Item No ____________________________________________
HC

AC / RC
Remarks