Form No.

19&10-C are required to be filled up at the time of leaving

service:Please fill in FORM NO.19 and FORM NO. 10- C (EPS) for withdrawal of Provident Fund
and Family Pension respectively. Please fill up the Form s in BLOCK LETTERS as
explained below:

Sr.
No.

Form No. 19

Sr.
No.

Your Name

Your Fathers
Name
(Keep Blank)

3
4
5
6
7
8

/Husbands

Full

2
3

(Keep Blank)
Date of Leaving our Organization
Write Resigned or Retired
(as applicable)
Full Postal Address of your
residence with pin code number
Mode of Remittance:

4
5
6

b
)

Please write

7
8

i. Your S/B/A/C No.

ii. Name of Bank with
Branch
iii Full postal address of
the
Bank with pin code
PLEASE
KEEP
ALL
OTHER
CLOUMNS BLANK

10
11

12

Form No. 10-C (EPS)

a. Your Name
b. Keep Blank
Your date of birth
Your
Fathers/Husbands
Full
Name
(Keep Blank)
(Keep Blank)
Write Resigned and mention the
Date of leaving our organisation
Full Postal Address of your
residence with pin code number
If you want Scheme certificate,
tick Yes / No (Write Yes in case
your membership is more than
10 years)
If you are married, write the
name of your spouse first,
followed by the name of your
children.
If unmarried, write the name of
your mother / father under 9 (b)
( Please do not write any details, if
Sr. No.8 is NO)
Write Not Applicable
Mode of remittance
Please Write :
Your Savings Bank A/c
No.
Name of Bank and
Branch
Full postal address of
the Bank With pin code
number
Give Pension details, if you are
availing, Else write N.A.

IMPORTANT NOTE:
Before returning the forms to us, please ensure that you have
signed at all the places ( 3 signatures on Form No.19 including
1 on revenue stamp and 2 signatures on Form 10-C including 1
on revenue stamp).

Fill form 10 C only if Service is more than 6 months.

Plz attach one cancelled cheque. (Single account No.) (pls
mention your ECN and name backside on Cheque)
Please enter contact details on the PF forms