FORM NO. 19

EMPLOYEES PROVIDENT FUNDS SCHEME 1952

for claiming the Employees provident fund Due's [Para-72 (52)]

Name of the Member : Fathers Name (Husbands Name in Case of Married Women): Name and Address of the Factory / Establishment in which the member was last Employed: PF Account No. : Date of Leaving Services : Full Postal Address shri / smt / kumari,
s/o , w/o , d/o: MODE OF REMITTANCE

By Postal Money Order at my Cost

By Account Payee cheque to be sent Direct for credit to my S.B. A/c (Scheduled Bank/PO) under inmitation to me

Name of the Bank Branch Full address of the Branch

Contribution for the current financial year :

A/c No. MH /

Month	Amount of Wages	CONTRIBUTIONS						Refund of Advance	Break in membership Reconable service	Remarks
		Worker's Shares			Employers Shares
		E.P.F.	F.PF	Total	E.P.F	F.P.F	Total
1	2	3(a)	3(b)	3(c)	4(a)	4(b)	4(c)	5	6	7
April
May
June
July
August
Sept.
Oct.
Nov.
Dec
Jan.
Feb
March
Total

Date :

Signature of the Employer,Official Seal

FORM NO.5

Date :

Name of the Employee :

Fathers Name (or Husband's Name in case of married women):

Age :

Sex :

Date of eligibility for new member/ date of joining the Estt. in case of old member:

Total Period of previous service(excluding period of breaks) as on the date of joining fund

Remarks previous A/c No. and particular of previous employer, any (if so whether he is a member of Family Pension Fund also)