Submitted online at UAN e-seva portal on 2024-07-09 10:07:13 (IP www.epfindia.gov.

in
Address:49.204.140.241)

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 - 9952064451
1. I want to apply for PF Advance
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 101604746528
3. Name of the member BALAJI

4. Date of Joining 31-May-2023

5. Permanent Account number / LFkk;h [kkrk la[;k DGQPB0452N

6.a Purpose of Advance Natural Calamities

6.b Amount of Advance (In Rs) 10000

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 T nagar Madley 2nd

Street,Chennai,CHENNAI,TAMIL NADU-
600017

Father/Husband/Spouse Name: RAMESH Date Of Birth: 30-May-1994

Bank Account Number 05340100018299 Bank IFSC Code BARB0STTHOM
Bank Details BANK OF BARODA,THOMAS MOUNT BRANCH
Aadhaar 59XXXXXXXX46
Member ID TNMAS00930010000018665
*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. 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 .
* 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.