Form 19
Form 19
Form 19
_________
4. PF Account No.:…………………….: /
Pin :
8. 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
( information to be furnished by the Employer if the Claim Form is Attested by the Employer)
Certified that the above contributions have been included in the regular monthly remittances.
............ .....................................................
Encl.
Declaration of non-employment
Note:- In the case of submission of application for settlement under clause (s) of sub-paragraph (i) and
in clause (b) of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1952, the claim should
be submitted after two months from the date of leaving service provided the member continues
to remain unemployed in an establishment to which the Act applies.
Date.............. ........... Signature or Left / Right hand thumb impression of the member
The space should be left blank which shall be filled Affix 1/- Rupee
in by Regional Provident Fund Commissioner/Officer Revenue
in-Charge of S.A.O. Stamp
HC AC / RC
Remarks