ete Numa mapa govin EMPLOYEES’ PROVIDENT FUNDS ORGANISATION ‘COMPOSITE CLAIM FORM (NON-AADHAR) ‘LEORM NO. 19 (PF FINAL SETTLEMENT/A0C (PENSION WITHDRAWAL BENEFIS)/24 (PF PART WITHDRAWAL} ‘Gaim appi {ick whichever fae apleatie) Tori) Fl PF Selenent (Ji) Penson Wiidrawal Beefis (—) TF PART WITHORAWALT—) Name ofthe mer (IN CAPITAL LETTERS) ‘a Uriel Ant Number VAN) bys PAF. Account No.(n case UAN nt avaiable) a by ‘adr Nur (or seeingy a) Fatiers Nae ) Mustanas Name w >: ate oF Dao ing ie exabicbment ‘Date of eaving Sve nat rau I appving for PF Pan Waray 3) Peinent Aezour Wo (PANY: (Ony case sence es than 5 yeas) (Pease encase two copies of Form No 15/154, applicable) 1b) Reason of ving Sec Servee terminated on account of (2) I beath of member (0) oneaction /Dscontnuation of employers buses or (c) Other (Cause bayond te eontel of the member = Personal Reasons 28) Pcpose of PF Pat Withdrawal (Tek whichever appcable) 8») Amount (in Rs) ©) For purpse of Se/Howse/Fat or Cnsruction trough “agency” or Repayment of Housing Loan or LIC, inca cheque fo be drn" pas of PF Par Witidranal ——TT T [Reusing Loan/Purchase of ste/reura iat or for Constvcsor/ton, alteration in estng howse/Repayment of Housing ean (ora 33 (ease attach» copy of canceled chequafattsted copy of fest page of Ps Book) Names dress ofthe Bank In fovour oF and payee’ adress, [Locket or cosure of acon (Pia 6 Ti_[Tness of meen arly (Pra 68 1 | Marioge of se sonaghteithe7 sister (Pca 68K), VW [Post Matulaton” education oF ehidren (Para 68K) | Natural colrity Para BL) we [Gut in elocticty in-esaiaiment Para am en an TB One yaa Before erent (Para GN] "| Enestnent in Vata Pension BemaTojaie Para GaN) Ti AUR eas or py ‘Saving Bonk Recount NO Fal Pose adress ‘The member hereby dedres tht he has not been enployd for bo mans (Vea) Ceres that te patcuiars are tre tothe best of my knowledge. 1 case the amounts used for any purpose othe than sated in column (10) above, ar able to retum the ene amour with penal meres Members Sinatre Employer's Sanatre Designatond Sel af EmpoyerINSTRUCTION SHEET FOR FILLING THE COMPOSITE CLAIM FORM (NON-AADHAR) Purpose of advance & documents required: (The purpose may be one ofthe folowing): a Dy ®) ») » v) vil) vil) by) Housing Loan/Purchase of site /house/flat or for construction/Addition alteration in existing hhouse/ Repayment of Housing loan: No document is requiced. New Declaration Forn/Utilstion Certificate required earlier has been discontinued, iiness of member/famiy: i) Certificate of doctor and i) Certificate by employer that ESIC facity is ‘ot avaiable to the member may be submitted by the member. Marriage of self/son/daughter/brother sister: No document Marriage Card is required Post Matriculation education of children: No document is required. Lockout or closure of factory/Cut in supply of electricity: No document is required "Natural calamity: No document is required, Purchasing equipment by physically handicapped: Medical certificate Is required. (One year before retirement: 90% of total PF balance can be withdrawn. No document is required, Investment in Varistha Pension Bima Yojana: 90% of total PF balance can be transfered to LIC. No document i required. No Revenue stamp (Re. 1/-)s required to be afficed by the member. Income Tax (TDS) fs deduced ifthe service is less than S years (60 months). No Income Tax (TDS) is deducted in ase the total balance is less than Rs. 50,000/-. However, TDS is deducted 10% ifthe member Submis PAN in such cases, In case PAN isnot submitted, then TDS @34.608% is deducted, The total service in the present establishment as well as previous estabishment is counted and, therefore, i is ‘advisabie to merge all PF accounts, Pension Withdrawal benefts con be availed only ifthe service i ess than 10 years.