Form 19 - Employees Provident Fund Scheme printable pdf download

Employees Provident Fund Scheme

Form 19

Paragraph 72(5) of Employees’ Provident Funds Scheme, 1952

Form to be used by a Major Member of Employees’ Provident Funds

Scheme, 1952 for Claiming the Employees’ Provident Fund Dues :

(Refer to Instructions)

1. Name of the member (in Block Letters) ……………………………………………

2. Father’s Name (or husband’s name in the case of married woman) …………..

………………………………………………………………………………………….

3. Name and address of the Factory/Establishment in which the member was

last employed …………………………………………………………………………

4. Account No. …………………………………………………………………………..

5. Date of leaving service ………………………………………………………………

6. Reason for leaving service ………………………………………………………….

7. Full Postal Address (in Block Letters)

Shri/Smt/Kumari ……………………………………………………………………...

S/o. W/o…………………………………………………………………….………….

PIN …………………………………………………………………….………………

Put a ‘tick’ in the box against the one opted (3)

( ) to the address given against item No. 7

( ) S.B. A/c No. in figure ………………………………………………………….

In worth……………………………………………………………

Name of the Bank…………………………………………………………………….

Branch…………………………………………………………………….……………

Full Address…………………………………………………………………….…….

8. Mode of Remittance …………………………………………………………………

(a) by postal money order at my cost

(b) by account payee cheque sent direct to credit to my S.B./A/c (Scheduled

Bank/P.O.) under intimation to me.

(Advance Stamped Receipt furnished below)

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

Date of Joining the Establishment ……………………………………………………..

Date of Leaving Service…………………………………………………………………

Form 19 - Employees Provident Fund Scheme