Form 19 - Employees Provident Fund Scheme (Page 3 of 5) in pdf

Form 19 - Employees Provident Fund Scheme Page 3

Signature of left/right hand thumb

impression of the member

(For the use of Commissioner’s Office)

A/c. settled in part/Full Entered in

F-21-A/224/29 Withdrawal Register.

Clerk

Head Clerk

(P.I. No.) ……………………………… (M.O./Cheque)………………………………..

Account No. ………………… (Section)………………………. Under Rs……………

Passed for Payment of Rs. …………………… in words)

M.O. Commission If any)

Accounts Officer

Net Amount to be paid by M.O.

Date …………………………..

Paid by inclusion in Cheque No. …………………………. dt………………………...

Vide Cash Book (Bank) Account No. 10 Debit Item No. …………………………….

H.C.

AC/RC

Remarks

Acknowledgment Card

Account No.

EPFO

Office of the RPFC/Officer-in

Charge of Sub-Regional Office

Acknowledgement

Received the following claims.

Registration No. ……………………….

EPF

Date Office Seal………………………..

FPF

……………………………………………

In case, no intimation is received within a

Month, you may write to the complaints

Postcard

Postage

Officer, Employees’ Provident fund duly

Prepaid

Form 19 - Employees Provident Fund Scheme Page 3