A.S.R.

Form

Regional Provident Fund Commissioner

Subject : For the settlement of Provident Fund Account No.

Dear Sir / Madam

I have applied for the settlement of my provident fund account number …………………………………………….
But of any reason issued money order / cheque ……………………………………………………………………………….
of ` ………………. /- dated ………/………/…………, in consequence of settlement of my
Provident Fund Account, has been returned to your office.

So, I request you to kindly sent the Money Order / Cheque of ` …………………………/- to below
mentioned address.

Bank Account Detail Home Address

Member Name : …………………………………………………
Bank Account No. : …………………………………………….
Bank Name : ………………………………………………………
Address : ……………………………………………………………
Pin Code : ………………………………………………………….
Member Name : …………………………………………………
Home Address : …………………………………………………
………………………………………………………………………….
………………………………………………………………………….
………………………………………………………………………….
Pin Code : ………………………………………………………….

(Attested by Previous Employer / Gazettted

Officer or By Bank Manager) Sincerely,
………………………………………………………………………….
Member Name
Signature ………………………………………………………………………….
Officer's Name & Seal of office Father / Husband Name

Advanced Stamped Receipt

Received a sum of ` ……………………/- [Rupees ……………………………………………………………………..]
by cheque …………………….. dated ……/………/………… payable at SBI, New Delhi, by Regional Provident
Fund Commissioner, New Delhi for the last disburrsement of my EPS Account / Advanvced D.L. /
in advanced payment card number…………………………………..

Signature of the Authorised Officer ` 1 Revenue Stamp

with Official Seal Member's Name & Signature