p.f. claim form
TRANSCRIPT
-
8/11/2019 P.F. Claim Form
1/6
To,
The Trustees,
ShapooriiPallonJl
&
Co.
Ltd.
Employees'Provident
Fund'
SP
Centre,
41 144,
Minoo
Desai Marg,
Colaba,
Mumbai 400005.
Date
ol
Application:
Dear
Sir
(s),
I
hereby
request
ycu
to
pay
the
amount
$anding
to
my credit
in
the
fund after
making such
deductions
as
may
be
authorized
under
the
kovident
F.rnd
Trust fuledlncome
Tax Act
1961
. My
particulars
are
as
below:
I
certify
that the
pillidlars
given
above
are
lrue
to
the best
ol
my
knowldge'
the nea
tuture.
I
hereby
agre
md
undertake
to kep
you
harmless
md lully
indemnilied
lrom
ad
againd
all losses,
@st or
dmages,
which
you
may sufter
or
inaJr
due to
my
withdrawal
of
provident tund
amount-hJving
being
proved
to
be
based on a
lal*
dedaration
at
ily tinle
in
future'
self-rti{ied
true
mpy
ol
dooment(s)
in
support
of my
appliation
iEare furnistled
/endosed.
[
ft'ror to
io'ilnms
SPCLwere
you
a Provident
Fund
Member
of
:
1
.
The Ernpioyeei'
ftovident
fund &
Miscellaneous
frovision
Act
,
1952
: Please
specify
:
ffiffiffiffiw
2.
ft.ovident
Fund
Recognized
under
lncome
Tax Act
1922
(1
1 of
1922) :
Please specify
:
ffiWWW
3.
A1y other
frovidcnt
Fund
Act :
Hease
Speci{y
:
wrffiffiwffiw,{ffi,
Name ot
Fl'ovident
Fund
WWWWffi
.
llad
you
applieci
for transier
of
frovident
fund
vide
form
No' 13
(Rev)
at the
time
of
loining
SPCL
:
Signature
of
EmPloYee
:
_ ._-_--
Name
of the
Member
(lN
BLOCI(LETTEFS
:
Father'd
Husband's
Name
(
I N
BLm(
LETTEFS)
Payroll
Region
P.F.
Account
No.:
MH/
BAN/
198441X|
P.AN.
No.
Date of
Erth
:
f*
I
Me4
I
YYYY
Date of
joining
kovident
tund
:
**
i ffiM
r YYYY
Date
of
leaving service
:
*tr} i
*&f8
I
YVY {
Fbasons
lor leaving
service
:
Oomplete
Residential
fustal
address
with
PIN Oode
(IN
BLOC}< LETTEFS)
(Also
enclose
self.cerlitied
true
copy
of residential
address
Proof
f
or communication
& Dispatch
of
Cheqqe
|
--'---
Personal
E-mail-id:
Telephone
with SID
code
:
ffithe
date of
joining
to date
of
leaving
issued
by
SPCL,
in
case
the
employee
is
having
membership
for
less than
5
Years.
Enclosed lor the vears:
i.
iii.
v.
ll.
iv.
ADVANCE
STAMPED
RECEI
PT
Beceived
from
$rapoorii
Pallonii
&
Oo.
Ltd.
Bnployees'
Bovident
fund
the sim
of
(
/-
(
fupees
--
Being
the
f
ull
payment of
ftovident
fund
Accumulations
to
the
credit
of my
ftovident
fund
Account
with them'
(
Name
&
Signature
of Claimant)
3
of
3
1211412012
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Evaluation
Only.
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by
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Edited
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PDF
Editor
Version
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Serial No:
For
Oftice
Use Only
In Words
No.
Form
No.10
C
(E.P.S)
EMPLOYEES'
PENSION
SCHEME,
1995
F1RM
To
BE
usED
BY
A MEMBER
oF
THE
EMPLIYEEI'pEtts,oN
sc HEMET
1
995
FO R
CLAIMING
VlITHDRAWAL
BEN
EFIT\SCHEME
CERTIFICATE
(Read
tlre
instructions
before
fillinq up
this
forml
2.
a) Name
of the member
:-
(
ln Block
Letters)
b)
Narne of
the
claimant
(s)
Date
Of Birth
a1 Father's
Name
l,--n
T-T-t
TT__l
b) Huslandls Nam-e
(lf
applicable)
4.
Name
& Address
of
the Establishment
in rvhich,
the
member lvas
last employed
Code
No.
&
Account
No.
Reason
for leaving
service
&
Date of
leaving
Full Postal
Address
:-
(ln
Block
Letlers)
MOBILENO.:
SHAPOORJI
PALLONJI
& CO.
LTD.
ADMINISTMTIVE
OFFICE
SP CENTRE,4Il44
M1NOO
DESAI
MARC,
COLABA,
MUMBAI
4OOOO5.
MIIIBAN/19844DV
RISIGNED
.
7.
PIN
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3/6
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lSvaluabon
Only.
Copyriglrt
(
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8/11/2019 P.F. Claim Form
4/6
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8/11/2019 P.F. Claim Form
5/6
(FOR
THE
LJSE
OF
COMMTSSIONER'S
OFFTCE)
(Under
Rs
M.O. Commission
(if
any)..........,.
...net amount
to be
paid
by M.O
tovrards vrithdrawal benefi
t.
D.H.
S.S
A.A.O
(FOR
USE
tN CASH
SECilON)
No.
10
Debititem No........
S.S
AC(A/cs)
.H
For
issue
if S.S:. IDS
is
enclosed.
D.H
S.S
A.A.o/APFC(A/cs)
(FOR
USE
tN PENSTON
SECTTON)
Scheme Certificate bearing
the
control
No........,.............:......................Issued
on.............................and
entered in
the scheme Certificate Control Register-
D.H
S.S
'A.A.O
APFC(PENSION)
-
8/11/2019 P.F. Claim Form
6/6
.:
.
DOCU
MENTS
REQUINE
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P;F AI'IOUNT
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7
qTEQUE
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8 PASS
B OOK B'ANi((CAI.{DIDATE)
9
CO\IERING
I-ETTER(CAI.{DIDATE)
10 DATE
OF BIRII{(CAI.{DIDATE)