Mobile No.

:
Regd. No. :

Employees' Provident Fund Scheme, 1952

Form - 19
Form to be used by a major member of the Employees' Provident Fund Scheme, 1952 for claiming the
Employees' Provident Fund dues [Para 72 (5)]

1.

Name of the member (in block letters)

SHYAMBAHADUR RAMDHANI PRAJAPATI

2.

Father's Name (or husband's Name in the case of married women)

RAMDHANI PRAJAPATI

3.

Date of Birth

Monday, October 28, 1985

4.

Name and Address of the Factory/Establishment in which the

member was last employed.

ACTIV EIGHT DIMENSIONS PVT LTD

CAPRI FIRST FLOOR, ANANT KANEKAR MAR
OPP HDIL TOWER, BANDRA EAST, MUM - 51

5.

MH\BAN\128336\0\13
100355178283

6.

P.F. Account No.

Universal Account Number (UAN)
Date of Joining

7.

Date of leaving Service

Sunday, May 31, 2015

8.

Reason of leaving Service

Personal

9.

Permanent Account No. (PAN)

ARPPP5496D

Wednesday, June 26, 2013

Whether Submitting form no. 15G/15H, if appicable

10.

if yes, Please enclosed 2 copy of 15H/15H

Shri/Smt/Kumari
Full postal address
S/o / W/o / D/o

11.

Mode of Remittance

(a)

By postal Money Order at my cost

(b)

By account payee cheque sent

Direct for credit to my S. B.
A/C (Scheduled Bank / P.O.)
under intimation to me.

( )

Yes
SHYAMBAHADUR RAMDHANI PRAJAPATI
TOPI WALA CHAWL, JAWAHAR NAGAR,
KHAR EAST, PAKKI BAWADI, PIPELINE
MUMBAI, MAHARASHTRA

Put a 'Tick' in Box against the one opted

)

To the address given against Item No. 10

S.B. Account No.
Name of the Bank

032001504646
ICICI BANK LIMITED

Address of the Branch

91, LADY JAMSHEDJI RO

IFS Code.

ICIC0000320

The member hereby declares that he has not been employed for two months (yes/no).
Certified that the particulors are true to the best of my knowledge.
The applicant signed/thumb impressed before me.

Member's Signature

Employer's Signature

Designation & Seal of emp

Date: 28-Sep-15

or Member's thumb impression

ADVANCE STAMPED RECEIPT (To be furnished only in case of 11(b) above)

Received a sum of * Rs __________________ (Rupees ___________________________________________ only) from

Fund Commissioner / Officer-in-Charge of Sub Regional Office _______________________________________

Affix 1.00 Rupee

Revenue Stamp

The space should be left blank which shall be filled in by

Regional Provident Fund Commissioner, Office-incharge
of Sub-Regional Office

Signature or Left / Right Hand thumb impression of

(For the use of Commissioner's Office)
A/c. Settled in Part / Full Entered in F-21-A/2
and withdrawal Register / Form 3 (F.P.F.) Form 9 (Revised)
Clerk
Under Rs _________________________________________________________________________________________

P.I. No. ________________

M.O. / Cheque
Passed for payment for Rs ______________

(In words) _________________________________________________________________________________________

M. O. Commission (if any)

Accounts Officer

Net Amount to be paid by M. O.

Dated

(FOR USE IN CASH SECTION)

Paid by cheque No ___________________ Date _________________________________ vide cash book and Account No 10 De
H. C.

A. C. / R. C.
REMARKS

9221549250

2 for claiming the

NI PRAJAPATI

PVT LTD
T KANEKAR MARG,
A EAST, MUM - 51

RAJAPATI
NAGAR,
PELINE
Pin No.

400 051

he one opted

No. 10

01504646
BANK LIMITED

ADY JAMSHEDJI ROAD, MAHIM

0000320

nature

& Seal of employer

Sep-15

b) above)

____ only) from Regional Provident

_______________ by deposit in my

x 1.00 Rupee
enue Stamp

umb impression of the member

Head Clerk

_________

Account No.

_________

unts Officer

Account No 10 Debit Item No.

/ R. C.

Mobile No. :

9221549250

For Office use only

Claim ID ___________________

EMPLOYEES PENSION SCHEME, 1995

Form No : 10 - C (E.P.S.)
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,
1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE

(Read the instructions before filling up this form)

1.

(a)

Name of the member (in block letters)

SHYAMBAHADUR RAMDHANI PRAJAPATI

(b)

Name of the claimant (s) :

SHYAMBAHADUR RAMDHANI PRAJAPATI

2.

Date of Birth

3.

Father's Name

RAMDHANI PRAJAPATI

Husband's Name (If applicable)

NA

Monday, October 28, 1985

4.

Name and Address of the Factory/Establishment in which the

member was last employed.

5.

Code No. & Account No.

Region / SRO Code

M

5A
6

ACTIV EIGHT DIMENSIONS PVT LTD

CAPRI FIRST FLOOR, ANANT KANEKAR MARG,
OPP HDIL TOWER, BANDRA EAST, MUM - 51

Estt. Code No.

A

128336

Date of Joining the Estt.

Wednesday, June 26, 2013

Reason for leaving service & Date of

leaving Service

Sunday, May 31, 2015

RESIGNED - PERSONAL

7.

Full Address (in block letters)

Shri/Smt/Kumari

SHYAMBAHADUR RAMDHANI PRAJAPATI

S/o / W/o / D/o

TOPI WALA CHAWL, JAWAHAR NAGAR,

KHAR EAST, PAKKI BAWADI, PIPELINE
MUMBAI, MAHARASHTRA

Member's Signature
or Member's thumb impression

Pin No.

Employer's Signature

Designation & Seal of employer

28-Sep-15
Date:

Yes

8.

Are you willing to accept Scheme Certificate

9.

Particulars of Family (Spouse & Children & Nominee)

Name

(a)

Family members

(b)

Nominee

10.

11.

Date of BirthRelationship with MembeName of the guardian

In case of death of member after attaining the age of 58 years without filling the claim :(a)

Date of death of the member

(b)

Name of the Claminant(s) / and relationship with the member

Mode of remittance (put a tick in the box against the one opted)
(a)

By postal money order at my cost to the address given against item No. 7

(b)

Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank)

S. B. Account No.

032001504646

Name of the Bank (In block letters)

ICICI BANK LIMITED

Full address of the Branch (In block letters)

91, LADY JAMSHEDJI ROAD, MAHIM

IFSC :
12.

No

ICIC0000320

Are you availing pension under EPS-95 ?

If so, indicate

PPO No ___________________

By whom issued _______________

Certified that the particulars are true to the best of my knowledge.

Signature or Left Hand Thumb
impression of the Member / claimant (s)

Employer's Signature

Date :

Designation & Seal of employer

28-Sep-15

Advance Stamped Receipt

(To be furnished only in case of 8(b) above)

Received a sum of * Rs __________________ (Rupees ___________________________________________ only) from Region

Commissioner / Officer-in-Charge of Sub Regional Office _______________________________________ by deposit in my Sav
towards the settlement of my Pension Fund Account.

Affix 1.00 Rupee

Revenue Stamp
Signature or Left / Right Hand thumb impression of the member

Certified that the particulars of the member given are correct and the member has signed / thumb impressed before me.

The details of wages and period of non-contributory service of the member are as under :
(Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund Office)
Wages ( Basic + D.A. ) as on 15.11.95 (if applicable)
Wages as on the date of exit

per month

Period of non contributory Service

Yeas / Month

Date :

No. of days

Signature of Employer / Authorised Official

(For the use of commissioner's office)

Under Rs _________________________ P.I. No. ____________________ M.O. / Cheque.
Passed for payment for Rs _______________ (in words) _____________________________________________
M. O. Commission (if any) _____________________ net amount to be paid by M. O. ______________________
Towards withdrawal benefit

D. H.

S. S.

A. AO

(For use in Cash Section)

Paid by inclusion in cheque No _________________________ Dated _____________________ vide Cash Book (Bank) Account
No ________________________

S. S.

AC (Cash)

For issue of S. S. ; IDS is enclosed

D. H.

S. S.

A. AO.

APFC (A/cs)

(For use in Pension Section)

Scheme Certificate bearing the control No ________________________ issued on _______________________ and entere
Certificate Control Register.

D. H.

S. S.

A. AO.

APFC (Pension)

MARG,
- 51
A/c No.
013

400 051

ployer

guardian of minor

________

mant (s)

ployer

rom Regional Provident Fund

t in my Saving Bank account

k) Account No. 10 Debit item

and entered in the Scheme