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Submitted online at UAN e-seva portal on 2023-09-14 15:35:02 (IP www.epfindia.gov.

in
Address:223.223.143.10)

deZpkjh Hkfo"; fuf/k ;kstuk] 1952


EMPLOYEES' PROVIDENT FUND SCHEME,1952
EMPLOYEES' Pension Scheme,1995
UAN Based Combined Claim Form 19/10C WB/31 for Advances/PF Final Settlement/Pension Fund Withdrawal
(mu ekeyksa esa ykxw tgka QkeZ 11(u;k)esa deZpkjh dk iwjk fooj.k] vk/kkj la[;k vkSj cSad [kkrk la[;k ;w-,-,u- iksVZy vkSj ij
miyC/k gS rFkk ;w-,-,u- esa lfØ; gSA)
(Applicable in cases where employee's complete details in Form 11(New),Aadhaar Number and Bank
Accounts details are available on UAN Portal and UAN has been activated.)
Mobile Number / eksckby uacj - 8989857467
1. I want to apply for PF Final Settlement
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100904279855
3. Name of the member SUBRATA KUMAR GHATAK

4. Date of Joining 01-Feb-2016


5. Date of Leaving Service/ NksM+us dk fnukad 30-Jun-2023
6. Reason of Leaving Service/ lsok NksM+us dk dkj.k RETIREMENT

7. Permanent Account number / LFkk;h [kkrk la[;k AJFPG9996D

8. Payee Address 360 A RAMNAGAR RAMPUR


rampur,JABALPUR,JABALPUR,MADHYA
PRADESH-482008

* eSa çekf.kr djrk gw¡ fd eSaus ;w , ,u iksVZy ij lhM MkVk dks Hkyh Hkk¡fr ns[k fy;k gS rFkk QkeZ u- 11( u;k ) cSad [kkrk fooj.k vkSj vk/kkj
la[;k lfgr lHkh MkVk lgh ik;k x;k gSA
* I certify that I have gone through the data seeded in UAN Portal and found all data including Form No.11
(New) , bank account details and Aadhar Number to be correct
Father/Husband/Spouse Name: SUNDAR GOPAL GHATAK Date Of Birth: 13-Jun-1963
Bank Account Number 20038402017 Bank IFSC Code SBIN0010466
Bank Details STATE BANK OF INDIA,GRANEDIERS REGIMENTAL CENTRE JABALP
Aadhaar 29XXXXXXXX87
Member ID MPJBP00085900000000208
* —i;k ;w-,-,u-iksVZy ij n'kkZ, x, cSad [kkrs esa Hkqxrku djsaA
* Please make payment in the bank account mentioned in the UAN portal .
UAN - 100904279855 Tracking ID - 10090427985501001

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