Form 19 - Employees Provident Fund Scheme (Page 2 of 5) in pdf

Form 19 - Employees Provident Fund Scheme Page 2

Contribution for the current financial year

Month……. Contribution…….. Period

Employ

Total

of break

Employ

Total

of break

if any

EPF

(Information tobe furnished by the employer if the claim form attested by the

employer)

Certified that the above contributions have been included in the regular monthly

remittance.

The applicant has signed/thumb impressed before me.

………………………………………………

……………………………

Signature of the employer or authorised Official

Signature of left/right

Thumb impression of the

member

Advance Stamped Receipt

Received a sum of Rs* ………………………. (Rupees*…………………………)

From Regional Provident Fund Commissioner/Officer-in-Charge of Sub-Regional

Office…………………………… deposit in my Savings Bank Account towards the

settlement of Provident Fund Accout.

* The space should be left blank which shall be filled in by Regional Provident

fund Commissioner/Officer-in-charge of S.R.O.

Affix 1

ruppes

Revenue

Stamps

Form 19 - Employees Provident Fund Scheme Page 2