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Form No 19
For Office Use Only Inward No.

EMPLOYEES PROVIDENT FUNDS SCHEME 1952 FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEMES, 1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES (PARA-72(5)). (Note: Read the instruction carefully before filing this form) (All correction/Alteration should be attested by the Employer)

1. Name of the Member (In block Letters) EMP No 02152386 2. Parent Name (Husbands name in case of the Married women) 3. Name and Address of the Factory/ Establishment in which the member was last Employed.

SRINIVASA ARUN KUMAR GARLAPATI DR.SEETHARAMANJANEYULU GARLAPATI

4. 5. 6.

Code No & Account No.

KN/16573/42470
Date of the Leaving Service

July 04, 2012

Reason of the Leaving Service

RESIGNED
HNO# 8-2-120/120/A/15/1,NANDINAGAR,BANJARA HILLS RD # 14, HYDERABAD,ANDHRA PRADESH. PIN : 500034

7. Full Postal Address (In Block Letters) Please furnish correct address/information

8. Mode of the Remittance Put a ticket against the any one

M.O

CHEQUE

X
(A) By postal money order at my cost if the amount Payable exceeds Rs.500/ (if the amount payable is Less than Rs.500/ M.O commission will be come by the PF Office. Payment Exceeds more then Rs.2000 above will not made through M.O. A. By Account payee cheque send direct for credit for the SB A/c any Scheduled Bank/Post Office/ Co-operative Bank) under intimation to me (Advance stamped receipt furnished below) Please furnish the S.B. A/c.No duly optioned in any nationalized bank/Scheduled Bank/ Co-operative bank with the Full postal address of the bank

to the address given in Item No 7 S.B A/c no E.C.S No Name of the bank Branch Full Address of the Bank

912010063425254

CERTIFED THAT THE PATICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date of Birth/Age Date of Joining the Establishment Date of Leaving Service _

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me. Date: Signature of the Employer/ Authorized Official with rubber stamp Signature/left hand thumb impression of the Member

Declaration of the Non Employment Note: in the case of submission of application for settlement under clause (E) of sib paragraph (1) and in clause(2)of paragraph 69 of the EPF scheme 1952 , he claim should be submitted after two months from the date of leaving service provided the member to remain un-Employed in an Est. to which the Act applies. Date: Signature/left hand thumb impression of the Member ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (B) above) Rupees_ from the Regional Provident Fund Commissioner/Officer in-charge of Sub Regional Office

Received a sum of Rs.

by deposit in my savings bank account towards the settlement of my Provident Fund Account. The space should be left blank which shall be filled in by Employer Provident Fund Office. Affix Re.1/Revenue Stamp

Signature/left hand thumb impression of the member on the Revenue Stamp FOR THE USE OF COMMISSIONERS OFFICE Account settled in Part/Full entered in F.21/A/24/2/9 and withdrawal register Clerk Under Rs. P.I No Section Rupess M .O.Commission if any Net Amount to be paid by M.O_ M.O/Cheque_ Passed for Payment for Rs. A/c N KN/BN_ (In Words) Only) Date_ EE Interest up to Amount Authorized Date: FOR USE IN CASH SECTION Paid in inclusion Cheque No (Bank) Account No 3 Debit Item No. C.W Acknowledgment received on S.S Remarks dated Vide cash Book A.A.O/A.P.F.C ER TOTAL Section Supervisor Only)

AAO Verified on

A.A.O/A.P.F.C

Form No 10-C (E.P.S) Employees Pension Scheme-1995

Inward No:

FORM TO USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
(Read the instructions before filing this form)
1 (A) Name of the Member (In Block Letters) (B)Name of the claimant (s) 2 Date of Birth 3 (A) Fathers Name (B) Husbands Name (If Applicable) 4. Name and Address of the Factory/Establishment in which the member was last Employed.

5.Code No & Account No

RO/SRO CODE EST. Code No

A/ c

no

6.Reasons for Leaving Services & Date of Leaving 7. Full Postal Address (In Block Letters) Sri/Smt/Kum S/o.D/o.H/o.W/o 8 Are you willing to accept Scheme Certificate in lieu Withdrawal Benefits?

Resigned

(A) Yes

(B) No

9.Particulars on Family (Spouse, Children or Nominee) Name of the Nominee (A) Family Member(s) (B) Nominee the Minor Date of Birth Relation with Name of the Guardian

10 Incase of Death of the member after the age of 58 years without filing the form. (A) Date of the Death of the Member (B) Name of the Claimant(s) and relation ship with the member. 11. Mode of the remittance (PUT A TICKET IN THE BOX AGAINST THE ON OPTION) (A) By postal Money Order at my cost to the Address given in the Column 7 (B) Account payee cheque sent direct for to my S.B A/c (Scheduled Bank under to me S.B A/c no ECS Code No Name of the Bank ( In Block Letters) Full postal address of the branch (In Block Letters)

credit intimation

12 Are you availing under EPS-1995 If so Indicate PPO No

by Whom issued

CERTIFED THAT PARTICULARS ARE TRUE TO THE BEST OF THE MY KNOWLEDGE

Date:

Signature/left hand thumb impression of the member/Claimant(s) ADVANCED STAMPED RECEIPT (To be furnished only in case of 11 (b) above)

Received the sum of Rs. (Rupees_ only) From the Regional Provident Fund Commissioner/Officer in-charge of Sub Regional Office, by depositing in my savings bank A/c towards the settlement of my Provident Fund Account. The space should be left blank which shall be filled by this office Affix Re.1/Revenue Stamp

Signature/left hand thumb impression of the member on the revenue stamp

Certified that the particulars of the member given are correct and the member has signed/thumb impression before me. The details of wages and period of non-contributory services of the member are furnished under Form- 3A/7(EPS) enclosed for the period for which was not sent the Employees Provident Fund Office Date of Joining Wages (Basic+D.A) As on 15/11/95 (if Applicable) Wages on the date of Exit Period of Non-Contributory Services Y M D

Date

Signature of the Employer/ Authorized official with Rubber stamp (FOR THE USE IN COMMISSIONERS OFFICE) P I No (Rupees) net amount to be paid by M.O S.S

Under (Rs. Passed for the payment for Rs. M.O commissioner (If any) Rs. benefit. D.A

M.O.Cheque

only) towards withdrawal A.A.O

Paid by inclusion in Cheque No Account No 10 Debit Item No D.A For issues of S.S :IDS is enclosed D.A S.S S.S

date

vide Cheque Book AC (CASH)

APFC (A/CS)

(FOR USE IN PENISION SECTION) Scheme Certificate bearing the control no scheme certificate control register D.A S.S Issued on and entered in the APFC (Pension)