Submitted online at UAN e-seva portal on 2024-07-10 12:57:40 (IP www.epfindia.gov.

in
Address:157.48.252.228)

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 - 7799243102
1. I want to apply for Pension Fund Withdrawal
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 101194314653
3. Name of the member LAXMI BHULAXMI

4. Date of Joining 01-Oct-2017

5. Date of Leaving Service/ NksM+us dk fnukad 07-May-2024
6. Reason of Leaving Service/ lsok NksM+us dk dkj.k CESSATION (SHORT SERVICE) - Any other
reason

7. Permanent Account number / LFkk;h [kkrk la[;k ATTPL5783H

8. Payee Address BOLLARAM

JINNARAM,HYDERABAD,MEDAK,TELANGA
NA-502325

* 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: LAXMI PARVATHEESWAR RAO Date Of Birth: 01-Jan-1979
Bank Account Number 162010100107276 Bank IFSC Code UBIN0816205
Bank Details UNION BANK OF INDIA,BACHUPALLY
Aadhaar 54XXXXXXXX78
Member ID APPTC00609380000011622
* —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 .
* The bank kyc has been online verified by bank and has been digitally signed by the employer for this case among
other validations and therefore mandatory uploading of the image of cheque leaf/attested bank passbook is not
required.