Form-19 - Employees' Provident Fund Scheme, 1952
( information to be furnished by the Employer if the Claim Form is Attested by the Employer)
Certified that the above contributions have been included in the regular monthly remittances.
The Applicant has signed/Thumb impressed before me.
............ .....................................................
Signature of Left/Right hand thumb impression of the member
Date......................................
Designation & Seal
Encl.
Declaration of non-employment
Note:- In the case of submission of application for settlement under clause (s) of sub-paragraph (i) and in
clause (b) of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1952, the claim should be
submitted after two months from the date of leaving service provided the member continues to
remain unemployed in an establishment to which the Act applies.
Date.............. ........... Signature or Left / Right hand thumb impression of the member
ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above)
Received a sum of Rs. ....................(Rupees .......................................................... .......................... from
Regional Provident Fund Commissioner / Officer-in-Charge of Sub-Accounts Office ..........................................
by deposit in my Savings Bank account towards the settlement of my Provident Fund Account.
Signature orLeft / 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/24/219 & withdrawal register.
Clerk
Section Supervisor
P.I.No.
-------------------------------------------------------------------------
M.O./Cheque
----------------------------------
Account No.
-----------------------------
Section
------------------------
passed for payment for Rs.
-------------------
¼
in words)
-------------------------------------------------------------------------------------------------------------------------------
M.O. Commission (if any) AOC/APFC
-----------------------------------
Net Amount to be paid by M.0……………………………Date………………..
(For use in Cash Section)
Paid by inclusion in Cheque No................................. ............................ date.................................................
vide Cash Book (Bank) Account No.3 Debit Item No ...............................................
HC AC / RC
Remarks
The space should be left blank which shall be filled
in by Regional Provident Fund Commis
sioner/Officer
in-Charge of S.A.O.
Affix 1/- Rupee
Revenue
Stamp
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