EPF Form 19 & 10-C Format

April 25, 2012
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 I have Attached EPF Form 19 & 10-C Format
Mobile:  98427 98427 Serial No.
For Office Use Only
In Words No.
Form No.10 C (E.P.S)
[Withdrawl Benefit]
EMPLOYEES’ PENSION SCHEME, 1995
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME,1995
FOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATE
1.     a) Name of the member (In Block Letters) ABC
        b) Name of the Claimant (s) ABC
2.     Date of Birth 0 5 0 8 9 2
3.     a) Father’s Name XYZ
        b) Husband’s Name (If applicable) NOT APPLICABLE
4.     Name & Address of the Establishment ABC COMPANY INDIA PVT LTD.,
        in which, the member was last employed X-18, 6th Cross Cut Road, Perundurai, Erode – 52.
5.     Code No. & Account No. Region/SRO Code TN / SL
Estt.Code No. A/c No.
XXXXX YYY
6.     Reason for leaving service CESSATION (SHORT SERVICE)
        & Date of leaving 1-Feb-2012
7.     Full Postal Address (In Block Letters)
        Shri/Smt/Kumari ABC
        S/o, W/o, D/o XYZ
1/12 – ANTI VALASA, MAKKUVA POST & TALUK,
Vizianagaram, A.P..   PIN: 535 547
8.     Are you willing to accept Scheme (a) (b)
        Certificate in lieu of withdrawl benefits Yes No √
9.     Particulars of Family (Spouse & Children & Nominee)
Name Date of Birth Relationship with member Name of guardian of minor
(a)   Family Members
PAPARAO 1966 FATHER –
PARVATHI 1976 MOTHER –
(b)   Nominee
PAPARAO 1966 FATHER –
PARVATHI 1976 MOTHER –
10.   In case of death of member after attaining the age of 58 years without filing the claim :-
        (a) Date of death of the member                                                        : Not Applicable
        (b) Name of the Claimant(s) / and relationship with the members  : Not Applicable
11.   MODE FOR REMITTANCE [PUT A TICK IN THE BOX AGAINST THE ONE OPTED]
        (a)    By postal money order at my cost to address given against item No.7
        (b)    Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation
                 to me √
                 S.B Account No. 1
                 Name of the Bank (In Block Letters) STATE BANK OF INDIA
                 Branch (In Block Letters) PERUNDURAI
                 Full Address of the Bank KOVAI MAIN
                 (In Block Letters) PERUNDURAI
12.   Are you availing pension under EPS-95?   :     No
        If so indicate:      PPO No. By whom issued
Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Text Box: @
Signature or left Hand
Thumb Impression of the
Date: 02-04-2012 Member / Claimant(s)
ADVANCE STAMPED RECEIPT
[To be furnished only in case of (b) 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 A/c towards the settlement of my Pension Fund Accounts
(The space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer-in-
charge)
Text Box: @

Signature or left thumb impression of the member on the stamp
Rs.1/-
Revenue
Stamp
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 as under :-
   Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employee’s Provident Fund Office)
   Wages (Basic+DA) as on 15.11.1995 (if applicable) : Not Applicable
   Wages as on the date of exit                                    : Rs.100.00 per day
  Period of non contributory Service
   Year / Month No. of Days
2011 / 10 17.0
2011 / 11 4.0
2011 / 12 2.0
2012 / 01 19.0
TOTAL 42.0
Signature of Employer/
Date: 04-02-2012 authorised official
(FOR THE USE OF COMMISSIONER’S OFFICE)
(Under Rs.____________________________________________________________________________________
P.I No._________________________________ M.O./Cheque
                                     Passed for payment Rs.___________________________ (in words)___________________
M.O Commission (if any)_________________ Net amount to be paid by M.O_______________________________
____________________________________________________________________________________________
towards withdrawl benefit.
D.H S.S A.A.O
(FOR USE IN CASH SECTION)
Paid by inclusion in cheque No._________________ Dt_________________vide cash Book(Bank) Account
No. 10 Debit item No.__________________________
D.H S.S AC(A/cs)
For issue if S.S;. IDS is enclosed.
D.H S.S A.A.O/APFC (A/cs)
(FOR USE IN PENSION SECTION)
Scheme Certificate bearing the Control No._________________ Issued on _______________________and
entered in the Scheme Certificate Control Register-
D.H S.S A.A.O
APFC (PENSION)

 

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