Application Form Towards Provident Fund Settlement printable pdf download

Application No.

NAME OF THE TRUST :

APPLICATION FORM TOWARDS PROVIDENT FUND SETTLEMENT

Date :

The Trustees

1. I, Mr. / Ms.

ceased to be an employee of

M/s.

with effect from

on account of :-

2. I, Mr. / Ms.

(nominee) submit the application

on behalf of my

Mr./Ms.

who

ceased

an employee of M/s.

with effect from

on account of:-

(please fill (1) if the claiment is Self or please fill in (2) if the claimant is Nominee) (strike off wichever is not applicable)

Retirement

Medical Unfitness

Death

End of Contract

Permanent Settlement Abroad

Resignation

Retrenchment

VRS

Termination

Dismissal

Others

(specify)

(Please tick whichever is applicable)

You are requested to settle my

Provident Fund a/c at the earliest I hereby solemnly declare

that since last two months, I am not employed in any establishment to which EPF Act 1952 Act is applicable.

(strike off if not applicable)

Signature of the employee / claimant

Please enclose a letter from the current employer if employed, and not covered by EPF Act 1952

EMPLOYEE PARTICULARS (TO BE FILLED IN BLOCK LETTERS)

1. Name of the Employee

Mr. / Ms.CS

2. Address for Communication

(Please state the address where you desire

Email :

Phone :

to your Cheque / DD to be sent)

3. Location / Unit

5. PF No.

7. Transfer in

6. EPS No.

8. Transfer in Date

4. Salary code / Roll No.

9. Date of Birth

10. Date of Joining Co.

11. Date of Joining PF

Cheque

DD / PO

DD Payable at

12. Mode of

Bank Name and

Send Cheque

Payment

Bank Address

Directly to Bank

PAN NO

Bank A/c No.

13. Nomination details :

(to be filled in case of death)

Relation

Percentage

Name of the Nominees

TO BE FILLED IN BY : HR / UNIT HEAD / CO-ORDINATOR / EMPLOYEE

14.

Month

Amount (Rs.)

15. Enclosures

a. Last Salary Drawn

(Tick appropriate boxes whichever is applicable)

b. P/F last deducted

a. Form 16

(if membership is less than 5 years for all the earlier years)

c.VPF last deducted

b. Visa Copy

(In case of going abroad)

d. Any other Contribution

c. Death Certificate

(In case of death)

e. PF Loan O/S

d. Doctor’s Certificate

(In case of medical unfitness)

(if any)

e. Wage Sheet

(In case of casual employees)

f. PF Loan Int. O/S

(if any)

f. Discharge Letter from the Company.

(In case of

HR/Unit Head/

Termination/Dismissal/Retirement) if provided by the company

Co-ordinator Signature

g. Final settlement Computation sheet

h. Have you submitted your application forms forsettlement

of Gratuity/Superannuation (if applicable)

Sent to HAIPL on

i. Any other document

(please specify)

Note : 1. Please see overleaf for Instructions.

2. Please send in your queries to infohos @ hewitt .com with the name of the company as captioned subject

3. Please log on to to know status on your applcaition (Provided your company has subscribed to web accesss facility)

4. Please quote the application reference no. for all your further correspondences.

5. PHOTOCOPIES OF THE FORM SHOULD NOT BE USED WHILE SENDING APPLICATIONS

Application Form Towards Provident Fund Settlement

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