Form 19 - Employees' Provident Funds Organisation Composite Claim Form (Non - Aadhar)
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EMPLOYEES’ PROVIDENT FUNDS ORGANISATION
EMPLOYEES’ PROVIDENT FUNDS ORGANISATION
COMPOSITE CLAIM FORM
COMPOSITE CLAIM FORM
(NON - AADHAR)
{Form No -19 (PF Final Settlement)/10C (Pension Withdrawal Benefits)/ 31 (PF Part Withdrawal)}
Settlement)/10C (Pension Withdrawal Benefits)/ 31 (PF Part Withdrawal)}
Settlement)/10C (Pension Withdrawal Benefits)/ 31 (PF Part Withdrawal)}
Claim Applies for
1. Final PF Settlement
1. Final PF Settlement
2.Pension Withdrawal
3.PF Part Withdrawal
3.PF Part Withdrawal
1
:
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Name of the Member (IN CAPITAL LETTERS)
Name of the Member (IN CAPITAL LETTERS)
a) Universal Account Number (UAN)
Universal Account Number (UAN)
3
b) PF Account No (in case UAN not
PF Account No (in case UAN not
available)
Aadhar Number: (for Seeding)
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a) Father’ s Name
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b) Husband’ Name
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Date of Birth
Date of Joining of the Establishment
Date of Joining of the Establishment
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Date of Leaving Service (Not required if applying
Date of Leaving Service (Not required if applying
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for PF part Withdrawal)
a) Permanent Account N.(PAN): Only in case of
Permanent Account N.(PAN): Only in case of
service less than 5 years)
Please enclose two copies of Form No.15
Please enclose two copies of Form No.15
G/15H, if applicable)
b) Reason of leaving Service:
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- Service terminated on account of (a) ill health
Service terminated on account of (a) ill health
of member (B) Contraction/Discontinuation of
Contraction/Discontinuation of
employer’s business or (C) other cause beyond
employer’s business or (C) other cause beyond
the of the control of the member.
- Personal Reasons
SN
Purpose of PF Withdrawal
Purpose of PF Withdrawal
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Housing Loan/Purchase of
Housing Loan/Purchase of
site/House/Flat or for
construction/addition, alteration in
construction/addition, alteration in
existing house/Repayment of housing
existing house/Repayment of housing
loan (Para 68B/68BB/68BC)
loan (Para 68B/68BB/68BC)
a) Purpose of PF Part withdrawal: (Tick
Purpose of PF Part withdrawal: (Tick
2
Lockout or closure of factory (Para 68H)
Lockout or closure of factory (Para 68H)
Whichever applicable)
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Illness of member/family(Para 68J)
Illness of member/family(Para 68J)
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Marriage of
b) Amount (in Rs.):
self/son/daughter/brother/sister (Para
self/son/daughter/brother/sister (Para
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68K)
c) For Purpose of site/house/Flat or
For Purpose of site/house/Flat or
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Post Matriculation education of Children
Matriculation education of Children
construction through “agency” or
construction through “agency” or
(Para 68M)
repayment of Housing Loan or LIC,
repayment of Housing Loan or LIC,
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Natural Calamity (Para 68L)
Natural Calamity (Para 68L)
indicate cheque to be drawn “in favour
to be drawn “in favour
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Cut in electricity in establishment (Para
Cut in electricity in establishment (Para
of” and payee’s address.
68M)
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Purchasing equipment by Physically
Purchasing equipment by Physically
Handicapped (Para 68N)
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One year before retirement (Para 68NN)
One year before retirement (Para 68NN)
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Investment in Varistha Pension Bima
Varistha Pension Bima
Yojana (Para 68NNN)
Saving Bank Account NO:
Bank Account Details for Payment:
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(Please attach a copy of cancelled
Name and address of the Bank
Cheque/attested copy of first Page of Pass book)
Cheque/attested copy of first Page of Pass book)
IFC Code :
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