Employees Provident Fund Scheme

Form 10
Paragraph 36(2)(a) & (b) of the Employees Provident Funds Sheme! "#$2
Return of Members leaving service during the month of
%ame and address of the Fatory&Estt' (ode %o
Sl'
%o
)ount
%o'
%ame of
member
(in blo*
letters)
Fathers %ame
(or husbands
name in ase of
married +oman)
,ate of
leaving
servie
-.easons
for
leaving
servie
.emar*s
" 2 3 / $ 6 0
Signature of the employer or other
authorised offier
,ate 1 22222222'' Stamp of the Fatory&Estt'
-Please state +hether the member is (a) retiring aording to Para 6# (")()) 3.
(4) of the sheme! (b) leaving 5ndia for permanent settlement abroad! ()
retrenhment! () part of a total disablement due to employment in6ury! (d)
ordinarily dismissed for serious and +ilful misondut! (e) disharged! (f)
resigning from or leaving servie! (g) ta*ing up employment else+here' (7he
name and address of the Employers should be stated) (h) ,eath! (5) attained the
age of $8 years'
) re9uest for dedution for the aount of a member dismissed for serious and
+ilful misondut should be reported by the follo+ing ertifiate:
;(ertified that the member mentioned at serial %o' 222222 Shri22222
222'' +as dismissed for serious and +ilful misondut' 5 reommend that the
Employers ontribution for 222222222' Should be forfeited from the
aount in the fund' ) opy of the order of dismissal is enlosed'<
;(ertified that the member mentioned at serial %o' 22222 Shri22222''
+as paid&not paid retrenhment ompensation of .s' 22222' =nder the
5ndustrial ,isputes )t! "#/0'<
Signature of the Employer