Submitted online at UAN e-seva portal on 2023-05-24 23:31:18 (IP www.epfindia.gov.

in
Address:157.41.195.249)

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 - 8249405908
1. I want to apply for PF Advance
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 100329714512
3. Name of the member SAMIKSHYA PANDA

4. Date of Joining 20-Mar-2010

5. Permanent Account number / LFkk;h [kkrk la[;k AQAPP4719K

6.a Purpose of Advance Purchase of Site for Construction of

Dwelling House

6.b Amount of Advance (In Rs) 1000000

7 In case of Advance for purpose of Site/House/Flat Not Applicable

8 Bankers details for Electronic Payment (Only for the Advance if payable to Not Applicable
third party)

9. Payee Address LAXMI VIHAR 16P NR INSTITUTE OF

PHYSICS,BHUBANESWAR,KHORDHA,ODISH
A-751005

Father/Husband/Spouse Name: PARITOSH PANDA Date Of Birth: 21-Nov-1977

Bank Account Number 02361050038234 Bank IFSC Code HDFC0000236
Bank Details HDFC BANK,CUTTACK - ORISSA
Aadhaar 86XXXXXXXX87
Member ID ORBBS00064920000000486
*Certified that the particulars are true to the best of my knowledge, 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 Aadhaar number to
be correct. Please make the payment in the bank account mentioned in the UAN Portal. A cancelled cheque
(containing member's name, bank account number and IFS Code) is attached herewith. In case the amount is used for
any purpose other than stated in column (6) above, I am liable to return the entire amount with penal interest.
* —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 - 100329714512 Tracking ID - 10032971451206001