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EMPLOYEE NO. :1004283

EMPLOYEES' PROVIDENT FUND ORGANISATION, 1952

COMPOSITE CLAIM FORM (NON ADHAAR)

[FORM NO] - 19(PF FINAL SETTLEMENT)/ 10C (PF WITHDRAWAL BENEFITS)/ 31 (PF PART
WITHDRAWAL)

1 Claim applied for: i) Final PF Settlement ( ) ii) Pension Withdrawal benefits ( ) iii) PF PART
WITHDRAWAL ( ) (Tick whichever is/are applicable)
2 Name of the member : (IN CAPITAL SATHISH R
LETTERS)
3 P.F. Account No.(In case UAN not a): MH/BAN/48475/1004283
available)
4 a): Father's Name : a): Ramasamy C
b): Husband's Name : b):
5 Date of Birth : 28-NOV-87
6 Date of joining the establishment : 07-JAN-15
7 a) Purpose of PF Withdrrawal: a): Outbreak of Epidemic or Pandemic
b) Amount : b): RS 1,00,000.00

8 Bank Account details for payment: Saving Bank Account :058001505146

No.
(Please attach a copy of cancelled Name of the Bank :ICICI Bank - Common for all
cheque/attested copy of first page of branches
Pass Book)

-Certified are true to the best of my knowledge.

-In case the amount is used for any purpose other than stated in column (7) above,I am liable
to return the entire amount with penal interest.

Member's Signature Employer's Signature

Date: 10/04/2020 Designation & Seal of Employer
Note: This is system generated Composite Claim Form and does not require Member and Employer Signature