EMPLOYEES’ PROVIDENT FUND ORGANISATION
“Bhavishyanidi Bhavan”, Near Income Tax Circle,Ashram Road, Ahmedabad-380 014
Instruction for filling up the Application (Form 19 and 10 – C (F.P.F.)
(For the guidance of applicant only, NOT to be sent alongwith the claims)

1. All the columns in the form should be filled in completely in ink, without any overwriting.
2. Against the column, “Reason for leaving service” indicate the one applicable.
a. Retired from service after attaining the age of 55 year / attained the age of 55 years.
b. Retired on account of permanent and total incapacity for work due to bodily mental infirmity.
c. Retired under voluntary retirement scheme.
d. Migrating from India for permanent settlement abroad.
e. Leaving India at least for a year.
f. Retrenched from service.
g. Discharged from service on receiving compensation under the Industrial Disputes Act, 1947.
h. Resigned and not employed in any factory to which the Employees’ Provident Funds Scheme applies.
3. Full postal address should be given clearly in Block letters.
Since the M.O. & payment intimation is to be sent to this address the name of the member and father’s (Husband’s) name should also be furnished in this column.
Correct postal Address including pin code will enable the Commissioner to make prompt payment to the correct payee.
4. It is advisable to have the payment by cheque. For this purpose the account payee cheque will be sent direct to the Scheduled Bank / Any Co. op. Bank / Post Office in which the S. B. A/c. is maintained under intimation to the member. This will expedite the settlements of the claim.
5. The literate member should sign the application form. Illiterate male member should affix his left thumb impression and illiterate female member should affix her right hand thumb impression and the fact should be clearly recorded below the thumb impression.
6. If the claim is required to be submitted after completing the prescribed period (i.e. in cases falling under items 2 (g) and (h) above only) the declaration of nonemployment in the application should be completed duly dated.
7. The claim application should be attested and Forwarded by the Employer under whom the Member was Employed.
If the member is unable to send the application through the Employer or duly attested by him for any reason whatsoever he may forward the claims duly signed
in the presence of any one of the following authorized officials and got attested overleaf with his official seal.
(i) Magistrate (ii) A Gazaetted Officer (iii) Post / Sub Post Master (iv) President of the Village Union (v) President of the Village panchayat where there is no Union Board (vi) Chairman / Member of the Municipal District Local Board (vii) Member of Parliament / Legislative Assembly (viii) Member of the Central Board of Trustees / Regional Committee Employees’ Provident Funds (ix) Manager of the Bank in which the Saving Bank Account is maintained (x) Head of any recognized Educational Institution (xi) any authorized official as may be approved by the commissioner.
8. The following document should be enclosed in support of the claim.
If the member retired on account of permanent and total incapacity due to bodily or mental infirmity a medical certificate from the ESI or if the Employee is not covered under the ESI Scheme the Medical Officer designated by the establishment should be attached.
In case of migration from India for permanent settlement aborad Visa, Passport, Journey ticket etc. should be sent for perusal and return.
9. Instruction to Employer before forwarding the claims.
Contribution in respect of the member should be shown in the Tabulor if form 3A Contribution Card to Commissioner is not already send. In case the contribution is not already paid, it should be remitted by separate challan and receipted tripicte challan be enclosed to the claim.
10. In support of claim under Employees’ Family Pension Scheme 1995, the period of break Non Pensionable service (i.e. period for which F.P.F. contribution is not payable) should be furnished, if not already initiated though contribution card.
11. The status of the claim can be verified from the Website www.epfindia.com
Note: If clim Form – 10C (FPF) alone is preferred Sr. No. 2, 6 and 8 are not applicable.
Form is available free of cost.
A/c. Gr. No.
Employer’s Tel. No :_____________
Member’s or Contact Tel. No:_____________
Inquiry Tel. No. : 27542251
Reg. No.
Employees Provident Fund Scheme, 1952
Form - 19
(For Office use only)
FORM TO BE USED BY A MAJOR OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952 FOR CLAMING THE EMPLOYEES’ PROVIDENT FUNDS DUES.
(Para-72(5))
(Refer to “Instruction”)
1. Name of the member (In Block Letters)
2. Father’s Name (Or husband’s name : In the case of married woman)
3. Name & Address of the factory / Establishment in which the member was last employed
4 Account No. GJ/
5. Date of leaving service
6. Reason for leaving service
7. Full Postal Address (In Block Letters) Shri/Smt./Kumari ____________________
S/o, W/o, D/o_______________________________________________________ ________________________________________________Pin : □□□□□□
8. Mode of Remittance : Put a tick in the box against the one posted
(a) By postal money order at my cost (Settlement of Claim up to Rs. 2,000/- only) to the address given against item No. 7
S.B. Account No.
Name of the Bank
(b) By account payee cheque sent direct for credit my S.B. A/c (Scheduled Bank/Co. op. Bank/P.O.) under intimation to me
Branch
Full Address of the Branch
(Advance Stamped Receipt furnished below)
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date of joining the Establishment _________________________________________ Date of Leaving Service ________________________________________________ Contribution for the Current year _________________________________________
Worker’s Shares
Employer’s Share
Month
Amount of wages
E.P.F
E.P.F.(difference between 10% & 8.1/3% OR 12% & 8.13% as the case may be)
PENSION FUND Contribution 8.13%
Refund of Adv.
No. of days/period of non-contributing service (if any)
Remarks
1
2
3
4a
4b
5
6
7
April
May
June
July
August
September
October
(a) Date of Leaving service, (if any)
November
December
January
(b) Reason of Leaving Service (if any)
February
March
Total
Information to be furnished by Employer if the claim form is attested by the employer
Certified that above Contribution have been included in the regular monthly remittance
The applicant has signed / thumb impressed before me
Signature of the employer of authorised official.
Signature of Left/Right hand thump impression of member
Date:
Designation and Seal
Encl:
Declaration of non – employment
I declare that have not been employed in any factory/Establishment to which the Act applies for a continuous period of not less than 2 months immediately preceding the date of my application for that withdrawl of my provident Fund money
Date:
Signature of Left/Right hand thump impression of the member
ADVANCE STAMPED RECEIPT
(To be furnished only in case of 8(b) above)
Received a sum of Rs _____________(Rupees__________) only from Regional Provident Fund Commissioner/Office-in-charge of Sub-Regional of Office ________ __________Gujarat State by deposit in my saving Bank Account towards the settlement of my provident Fund account.
The Space should be left black which shall be filled in by Regional Provident Fund Commissioner / Office-in-charge of S.R.O.
Affix Rs. 1/- Revenue Stamp
Signature of Left/Right hand thumb impression of the member
FOR THE USE OF COMMISSIONER’S OFFICE
F21 A/2/9/3 (FPF) A/c. settled in Part/Full Entered in F21 A/2/9/3 (FPF) withdrawal register.
Clerk
S. S.
(Under Rs. __________________)
P.I.No. M.O./Cheque / Account No._______________________________________ Section __________________________________________
Passed for payment Rs. (in words) Rs.
M.O. Commission (if any) Rs. __________________________
Net amount to be paid by M. O.
Date
A.A.O./A.C.
(FOR USE IN CASH SECTION)
Paid by inclusion in cheque No. ______________ Date ___________ Vide Cash Book (Bank) Account No. 3 Debit item No. _______________
S. S.
A.C.
R.C.
REMARKS