Smt.

Kanlaben Mahendrasinh Jadeja

E-nail - rishijadeja @yahoo.com
Sub: PF/EPS claim in r/o bearing PF A/c No. GI/43804/4801
Ref.: MOL BR/E/2022/6361 2, Dated : 07.09.2022

members
and reference, it is inform you that
Sir,
With reference to the above cited subject
has bnen approved on 08.09.2022 with PE R:
death claim PF (f.no. 20) and EDL (fn. 5!F)
176719/- and EDU Rs. 418759/-.
member
pension (frcm no. 10D) due to deceased
Further, claimant is not eligible for widow complete 10 years service so please subit foIm
has been died after complete 58 ycars without respect of claimant.
no. 10C for withdrawaiwith supportingdocuments in
This is for your information please.

Yours Faitefuil,

Regional P Commissionet
Regidnal office, Rajkct

6ecIVED
FOR R.PF.C. R'AJKOT
 O04443434

EMPLOYEES' PROVIDENT FUND ORGANISAT!ON

COMPOSITE CLAIM FORM (NON-AADHAR)
[FORM NO.-19 (PF FINAL SETTLEMENT/10C (PENSION
WITHDRAWAL BENEFITS/31 (PF PART WITHORAWAL))
Claim applied for: i)Final PF Settlement( )i) Pension
1
(Tick whichever is/are applicable) Withdrawal Benefits (V )ii) PF Part Withdrawal (
2 Name of the member :(IN CAPITAL
LETTERS) MAHENDRASINH JETUBHA JADEJA
a): Universal Account Number (UAN)
3 a): 100753073834
b): P.F.Account No. (in case UAN not
available) b): GJ/RAJ/43804/4801
4 Aadhar Number (for seeding) :
5
a): Father's Name:
b): Husband's Name: a): JETUBHA JADEJA
6 Date of Birth: b):
01.01.1962
7 Date of Joining the
Establishment: 01.04.2016
8 Date of leaving service:(not if required applying for PF Part
Withdrawal) 12.02.2022
al Permmanent Account
than 5years)
No.(PAN)}: (ony in case of servise lezs
(Please enciose twO copies of Form No. 15G/15H, if
applicable)
b) Reason of leaving Service:
Service terminated on account of (a) t heaith of
member (b) DEATH IN SERVICE
contraction/ Discontinuation of employer's business or (c) Other
beyond the control of the member cause
Persona keasons
10 a) Purpose of PF Part
b) Amount (in Rs ):
Withdrawal:(Thik v whicheverapplicable)
SN Purpose of PF Part Withdrawal
|c) For purpose of Site/House/Flat or
Construction through "agency"
or Repayment of Housing Loan or LIC, indicate
Housing Loan/Purchase of site/House/flat or for
cheque to be drawan |Construction/Addition, aiteration in existing house
"in favour of" and payee's address. |/Repayment of Housing loan (Para 68B/68B8/688C)
Lockout or ciosure of factory (Para 68H)
III ness of member/famiy (Para68H)
IV
Marriage of selt/son/daughter/brother/sister (Para68K)
Post Matriculation education of children (Para
68Kj
VINatural calamity (Para68L)
VI Cui tseiecirity in estauishrnent Pra 6oivi)

VIlI Advance for Physicaily handicapped (Para 68N)

IX One year before
retirement (Para 68NN)
X
Investment in Var stha Pens on B ma
Yojana (Para 68NNN)
11Bank Account details for payment: Saving Dank Account No.
(Please attach a copy of cancelled cheque/ attested copy of first 40884298273
page of Pass Book)
Name &address of the Bank:
STATE BANK OF INDIA, KHODIYAR
COLONY,
JAMNAGAR, GUJARAT-361006
IFS Code:SBINO012211
12 Fuli Postal Address: 1, NILKAMAL SOCIETY, OPP
KHODIYAR COLONY,
JAMNAGAR, GUJARAT.
The member hereby declares that he has not been Pin: 361006
employed for two months (Yes/No)
Certified that the particulars are true to the best of ny knowledge.
n case the amount is useu rary purpuse otner than stated in cOurnn (lý) aove, i amn iabie tu return the
entire amount witn penat interest.

Member's Wife Signature Employer's Signature

Designation &Seal of Employer
Industrial Energy Solutions

Harshvardhan Gupta
(Patneh.
 3CVEATNTONO

Jade,a NMahendrasinh
4 tt0O8 O1/0/1962
42 7MALE

9359 2306 1965

EEN#CATCN AUTHORIYCE DA
Address:
khodiyar coiony Anar, Jaraçar
Guaa- 361 006

it- 361006

9359 2306 1965

Industrial Enerqy olutions

Harshvardhan Gupta
(Partmg
INCOMB TAX DEPAKTMENT
GOVT. OF INDIA
MAHENDRASINH JADEJA
JETHUBHA RAGGBHA JADEJA
01/01/1962
Pertnanent Account Numhor
BGJPJ4065N 3122018

Sighature

Industrial Energy Solutons

Harshvardhah Gpta,
(Parther
 a4-6 FORM-6

GOVERNMENT OF GUJARAT

DEPARTMENT OF HEALTH AND FAMILY wELFARE DA 0993147

DEATH CERTIFICATE
(ssued under Section 12/17 of the Registration of Births and Deaths Act J969 and Rule &of
the Guiarat Registration of Births and Deaths Rules, 2013)

This is to certify that the

following iofonaion has been taken
Village/City Lakhiya Nana of Taluka from the original record of death which is in
Lalpur of District Jamnagar the register lor
ol H/Name: HéçRiu 1 of Gujaral State, India
/
H220 tl lu Date of Death : MAHENDRASINH JADEJA aa/Sex Y3 /Male
12/02/2022
Saturdav. February 12, 2022 H22 2n Place of Death
Hldloj otH/ Name of Mother NANA LAKHIYA
^4U / HAMBA Qto-ui ollH / Name of Father or
Husband:
H2olRott Hy 4lo H24/ Address of gel JATUBHA
Death : deceased at the time of HlollRj s1l 2otlY/
Mt-u q4qUNANA LAKHIYA Permanent address of
Deceased
olul sAIS/Registration No. 3 tu q4le¯NANA LAKHIYA

lua (alu u)/ Remarks (if any) lluelol ulu Dale of Registration
:18/02/2022
yHRUa ou? Cerlilicale No :
D202210079294
yHQUA sal Llloll tllu Date of issue:
artulsilol
15/03/2022
authorily: AS/Signature of issuing

Industrial Energk Solutions

Harshvardhan upta
(Parther)

Y/YATZkd4u6tZ93nuGüDAvgheQWow6du V42+6 VOE=

.91...4. (4) 104- 1Y,00,000-40-2020
 Government of India
lssue
Dae:
0/12/2021

Jadeja Kamlaba Mahendrasinh

YeN ad/DOB: 01/06/1964
FEMALE

3544 1406 0753

VID : 9163 87Z1 5848 9100

Uníque ldentification Authority of India

i21: s4UNON, 1, dasue aaa, wßaa lel
red-361006
3Address:
CIo: Kamlaba, 1, Nikamal Society, Opp.
EKhodiyar Colory, Jamnagar City, Jamnagar,
Gujarat - 361006

3544 1406 0753

VID:9163 8771 5848 9100
1947
Aelpuldai.gov.in E ww.ulda.gov.ln

Industrial Enery $olutions

Harshvardhan GUgtá
(Pagher)
INCOME TAX DEPARTMENT GOVT. OF INDIA

PeTaNert AcCDUn N e Cad

HJFPM1669N

RIName
JADEJA KAMLABA MAHENDRASINH
Rar TR IFathers Kame
SARDARSANG VAGHELA
Dte
48501
01/06/1964, TAT|Signature

Industrial Energy Solutions

Harshvardhan Gupt
(Patner)
 R
eAccwalwa
RSTGENERALLY USED ABBREVIATIONS
Csh= Cash/
dË "AdjustmenthstR Pos &Point of Salez s
dep Deposit/a
Amt Amount/afA
DftDraft/e PrPrincipal/q
Ar= Arrear/esrc proc Processing Charge/s
dish/dsh -Dishonori ga
bal= Balance/às rd Recurrng Deposit/d
DRDebit/
CapnCapitalsalion ia DOB Date
retrtn Return/et
of
Chg/ch Charge/ Birthaabe
eft Electronic Fund Transfert(ès
Chq= Cheque/ès sb= Savings Bank/e ts
CE = Customer InopInoperative/R SC Short Credite
information Fle/ q HA Ins Insurance/g
Clos =Closure/u SI/So/SORD Standing Instruction/ertaR
Int /In interest/a
Cot- Cotection/s S/DrWIHo Son/Dughter/Wfe/Husband oll gtt
ionioan/s
Comm. Commission/sha tr/trfltfer Transfer abe
min =Minimum/a4
COR/CORR Correction/tavA tun= Transaction/
os =Outstanding/wt
CR- Credit/ Wdl Withdrawal/Ta
P&T- Postal Charges/es
"MOD bal Total balance (SB"lnked MOD Jcl/hv (egte+ d warg

Eranch: KHCDIYAR COLCNY

DSBI 4Rty tz SHASTIK TIMDER & HARWARE DUILD
STATE BANK OF INDI:S
Email:ski.12211@sbi.co.in
Phon: .. i1271 uSs. Hrs:.00.3-1..00
IFSC: 6INOO12211 HCR. 610020:
ane: "Nrs. Jaie12 aaba Nahendrasin
3/D/H/o :Gardarsinh Vaghela 10F: 3INGLE
CIF NURc:: 90936865S47 A/= Opening Dt: 30/03/2022
4080420273 o Reg No: 00000093303241

LONTINUAIICN
Fore NO.

U.0.3.ii Minori:

BRANCH MANAGER

Industrial Energ\Solutions

Harshvardhàn ups
(PartHer)
 OF
SPECIMEN SIGNATURE DETAILS
GJ/RJTI43804
Employees Provident Fund Organization
005.
Sub: Regional Office, Rajkot-360

SOLUCTION.
Nane of Establ1shment :MIS INDUSTRIAL ENERGY
COLONY, JAMNAGAR
Address : 107. D[VYAM COMPLEX, KHODIYAR
E- Mail D

Telephone
Fax

Authorized Signatoy / Signatories SPECIMEN

SPECIMEN SPECIMEN
SIGN ATURE SIGNATURÉ
NAME& MOBILE NO. DESIGNATION SIGNATURE

PARTNER
PKRISHNAN NAJR

HARSH VARDHAN GUPTA PARTER

Special instructions ( if any ):

Counter Signature of Employer
Name :P KRISHNAN NAIR Industrial EnergySoltians
Designation : PARTNER
Establishment seal
nerg,
iotutio PkNair
(Partner)