Shri/Smt ...............................(in block letters) S/o/W/o/H/o/D/o...................................
PIN ........................
5. 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 in Item No. 4
or(b) by account payee cheque sent direct for credit to my S.B. A/c. (Sch. Bank/Post Office) under intimation to me
*S.B. Account No.....................................
(Advance Stamped Receipt)
Bank
......................................................
furnished below:
Branch
...................................................
Full address ofBank
................................
Certificate
- To the best of my knowledge no posthumous child will be born to the deceased member.
- I certify that the particulars given above are true to the best of my knowledge.
- I certify that the minor(s)/lunatic Shri/Smt/............................is living with me and is being supported and looked after by myself and the Provident Fund money claimed on behalf of minor/lunatic will be spent in his/her best interests and benefit.
- I certify that the minor member has not been employed in any factory/ establishment to which the Act applies for a continuous period of not less than 6 months immediately preceding the date of the application.
Enclosure
Date ...........................
Signature or left/right hand thumb-impression of the claimant
*delete if not applicable.
Advance Stamped Receipt
[To be furnished only in case of 5(b) above]
Received a sum of Rs. ............... (Rupees.............) from Regional Provident Fund Commissioner/Officer-in-Charge of Sub-Regional office ..................by deposit in my Saving Bank Account towards the settlement of Provident Fund Account of Shri/Smt .............
Affix Re. 1 Revenue Stamp
Signature or left/right hand thumb impression of the claimant
*The space should be left bank which shall be filled in by RPFC/Office-in-Charge of S.R.O.,
Certificate of the attesting authority
CONTRIBUTION FOR THE CURRENT PERIOD
CONTRIBUTION FOR THE CURRENT PERIOD
Month
Contribution
Period of break, if any
Month
Contribution
Period of break, if any
Employee
Employer
Total
Employee
Employer
Total
EPF
FP
EPF
FP
EPF
FP
EPF
FP
EPF
FP
EPF
FP
- Certified that the above contributions have been included in the regular monthly remittances.
- Certified that the facts stated above are correct.
- Certified that the claimant Shri/Smt./Kumari .......................................is known to me and has signed/thumb-impressed before me.
Signature of the Employer or Authorised Officer
Designation and Office Seal ...................................
For the use of Commissioner's Office
Account settled entered in Form 21-A/24/2/9 (Revised) & Withdrawal Register.
Clerk
Head Clerk
P.I. No ....................... M.O./Cheque........................... Account No.........................
Section .....................
Passed for payment for Rs ..................(in words)
M.O. Commission (if any) ............
Net amount to be paid by M.O ......................
Date ..........................
Accounts Officer
For use in cash section
Paid by inclusion in Cheque No ...................................dated...............................vide Cash Book (Bank) Account No. 3 Debit Item No ...............................
Head Clerk
Assistant Commissioner/Regional Commissioner
Remarks ...............................................................................................................................................
ACKNOWLEDGEMENT CARD
Account No ...........................EPFO Office of the RPFC/Officer-in-Charge of Sub-Regional Office
ACKNOWLEDGEMENT
Received the following claims: .......................................................
Registration No. .........................................................
EPF..........................................................................................
Date........................................................................
FPF ..........................................................................................
Official Seal ..............................................................
IF.............................................................................................
Post Card
In case, no intimation is received within a month, you may write to the Complaints Officer, Employees' Provident Fund duly quoting the Registration Number and your Provident Fund Account Number.
Postage Prepaid
.................................................
.................................................
PIN.............................................
Employees' Provident Fund Organisation
Office of the Regional Provident Fund Commissioner/S.R.O .............................................
Full Address ................................................................
Instructions
(For the guidance of applicant only, not to be sent along with the claim)
The following instruction should be carefully read before completing the form: