Affidavit-Cum-Indemnity Bond Form printable pdf download

AFFIDAVIT-CUM-INDEMNITY BOND

Passport Size

Photo

(Sign on the photo)

I._____________________________ (Block letter) S/o, D/o, w/o _____________________________________________

Residing at: -

-----------------------------------------------------------------------

Permanent Address: -

___________________________________________

Taluk ___________District______________________

State ___________________Pin Code ____________

Phone Number:_______________________________

E-mail Id:

_______________________________

Solemnly affirm and state on oath as under:-

1. I state I was an employee with (Name & Full Address of Establishment) is

From _______________to ____________and holding P.F Account No. _______________________ with REGIONAL

PROVIDENT

FUND

COMMISSIONER,

(PF

Office

address)

______________________________________________________________________________________________________

_______________________________________________________________________and DECLARE that I am the Actual

Provident Fund Account holder.

2. I am herewith submitting PF Claim Forms 19 / 10c / 13 and I hereby undertake an indemnity to Central Board of Trustees

Employee’s Provided Fund Organization, Ministry of Labour, Government of India that this claim if later found false, I shall be

responsible for any loss incurred out of this transaction.

3. I declare that I have NOT withdrawn / transferred my PF Accumulation / withdrawal benefit of FPF 1971 / Employee’s Pension

Scheme’1995 till date (dated ________________) in respect of my above account.

This Affidavit-cum-Indemnity Bond has been executed by me and state that the facts mentioned therein are true and correct.

Deponent

(NAME)

Solemnly affirmed / identified and signed before me

On this day of ______________

ADVOCATE

(With seal)

Identified / Witness (2 Nos.):

BEFORE ME

Name & Address /Contact No .

Class Judicial Magistrate / Public Notary)

(With seal)

IDENTIFIED BY:-

In support of proof of Identify I am self attesting duly attested by notary / Gazetted Officer the following documents -



1. PAN Card

2. Appointment letter issued by the company / pay slip



3. Passport / Election Card

4. Bank pass book with address, latest signature attested by

the bank manager

Date:

Place:

Affidavit-Cum-Indemnity Bond Form

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