1. Name of the Member (In block Letters) EMP No 02152386

SRINIVASA ARUN KUMAR GARLAPATI

2. Parent Name (Husband’s name in case of theMarried women)

DR.SEETHARAMANJANEYULU GARLAPATI

3. Name and Address of the Factory/ Establishment in which the member was last Employed.

4. Code No & Account No. KN/16573/42470

5. Date of the Leaving Service July 04, 2012

6. Reason of the Leaving Service RESIGNED7. Full Postal Address (In Block Letters) Please furnish correct address/information

HNO# 8-2-120/120/A/15/1,NANDINAGAR,BANJARA HILLS RD # 14, HYDERABAD,ANDHRA PRADESH. PIN : 500034

8. Mode of the RemittancePut a ticket against the any one M.O CHEQUE

X

(A) By postal money order at my cost if the amount Payable exceeds Rs.500/ (if the amount payable is Less than Rs.500/ M.O commission will be comeby the PF Office. Payment Exceeds more thenRs.2000 above will not made through M.O.

to the address given in Item No 7

A. By Account payee cheque send direct for credit for the SB A/c any Scheduled Bank/Post Office/Co-operative Bank) under intimation to me (Advance stamped receipt furnished below) Please furnish the S.B. A/c.No duly optioned in any nationalized bank/Scheduled Bank/Co-operative bank with the Full postal address of the bank

S.B A/c no 912010063425254

E.C.S No

Name of the bank

Branch

Full Address of the Bank

Contact No: +91-8805687008 Personal Email id: garlapati.srinivasa9@gmail.com Form No 19

For Office Use OnlyInward No.

EMPLOYEE’S PROVIDENT FUNDS SCHEME 1952FORM TO BE USED BY A MAJOR MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEMES,

1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES (PARA-72(5)).

(Note: Read the instruction carefully before filing this form)(All correction/Alteration should be attested by the Employer)

CERTIFED THAT THE PATICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date of Birth/Age

Date of Joining the Establishment

Date of Leaving Service _

Certified that the particulars of the member given are correct and the member has signed/thumb

impressed before me. Date:

Signature of the Employer/ Signature/left hand thumb impression of theAuthorized Official with rubber stamp Member

Declaration of the Non Employment

Note: in the case of submission of application for settlement under clause (E) of sib paragraph (1) and in clause(2)of paragraph69 of the EPF scheme 1952 , he claim should be submitted after two months from the date of leaving service provided the member to remain un-Employed in an Est. to which the Act applies.

Date: Signature/left hand thumb impression of theM

ember

ADVANCE STAMPED RECEIPT(To be furnished only in case of 8 (B) above)

Received a sum of Rs. Rupees_ from the Regional Provident Fund Commissioner/Officer –in-charge of Sub Regional Office

by deposit in my savings bank account towards the settlement of my Provident Fund Account.The space should be left blank which shall be filled in byEmployer Provident Fund Office. Affix

Re.1/- Revenue Stamp

Signature/left hand thumb impression of the member on the Revenue Stamp

FOR THE USE OF COMMISSIONER’S OFFICEAccount settled in Part/Full entered in F.21/A/24/2/9 and withdrawal register

Clerk Section Supervisor

Under Rs. Only)

P.I No M.O/Cheque_ A/c N KN/BN_ Section Passed for Payment for Rs. (In Words) Rupess Only)M .O.Commission if any Date_ Net Amount to be paid by M.O_

EE ER TOTALInterest up toAmount Authorized

Date: A.A.O/A.P.F.C

FOR USE IN CASH SECTIONPaid in inclusion Cheque No dated Vide cash Book(Bank)Account No 3 Debit Item No.

C.W S.S AAO A.A.O/A.P.F.C Remarks

Acknowledgment received on Verified on

Form No 10-C (E.P.S) Employees Pension Scheme-1995

Inward No:

FORM T O U S ED BY A MEM B ER O F TH E EMP L O Y EES P E N SI O N S CH EME 1 9 95 FOR C LA I MING WI T H D R A W AL B EN EFIT/S C H E ME C E RT IFI C A T E

(Re ad the inst ru ctio ns befo re filing t his fo rm )

1 (A) Name of the Member (In Block

Letters) (B)Name of the claimant (s)

2 Date of Birth

3 (A) Father’s Name

(B) Husband’s Name (If Applicable)

4. Name and Address of the Factory/Establishment in which the member was last Employed.

5.Code No & Account No RO/SRO CODEEST. Code No A/ c no

6.Reasons for Leaving Services Resigned& Date of Leaving

7. Full Postal Address (In Block Letters) Sri/Smt/Kum

S/o.D/o.H/o.W/o

8 Are you willing to accept SchemeCertificate in lieu Withdrawal Benefits? (A) Yes (B) No

9.Particulars on Family (Spouse, Children or Nominee)

Name Date of Birth Relation with Name of the Guardian of

the Nominee the Minor

(A) Family Member(s)

(B) Nominee

_

10 Incase of Death of the member after the age of 58 years without filing

the form. (A) Date of the Death of the Member

(B) Name of the Claimant(s) and relation ship with the member.

11. Mode of the remittance (PUT A TICKET IN THE BOX AGAINST THE ON OPTION)

(A) By postal Money Order at my cost to theAddress given in the Column 7

(B) Account payee cheque sent direct for credit to my S.B A/c (Scheduled Bank under intimationto me

S.B A/c no

ECS Code No

Name of the Bank ( In Block Letters)

Full postal address of the branch (In Block Letters)

12 Are you availing under EPS-1995 If so IndicatePPO No by Whom issued

CERTIFED THAT PARTICULARS ARE TRUE TO THE BEST OF THE MY KNOWLEDGE

Date: Signature/left hand thumb impression of the member/Claimant(s)

ADVANCED STAMPED RECEIPT

(To be furnished only in case of 11 (b) above)

Received the sum of Rs. (Rupees_ only)From the Regional Provident Fund Commissioner/Officer –in-charge of Sub Regional Office, by depositing in my savings bank A/c towards the settlement of my Provident Fund Account.

The space should be left blank which shall be filled by this office Affix

Re.1/- Revenue Stamp

Signature/left hand thumb impression of the member on the revenue stamp

Certified that the particulars of the member given are correct and the member has signed/thumb impression before me.

The details of wages and period of non-contributory services of the member are furnished under Form- 3A/7(EPS) enclosed for the period for which was not sent the Employees Provident Fund Office

Date of Joining

Wages (Basic+D.A) As on 15/11/95 (if

Applicable) Wages on the date of Exit

Period of Non-Contributory Services Y M D

Date Signature of the Employer/ Authorized official with Rubber stamp

(FOR THE USE IN COMMISSIONER’S OFFICE)Under (Rs.

P I No M.O.Cheque Passed for the payment for Rs. (Rupees) only)M.O commissioner (If any) Rs. net amount to be paid by M.O towards withdrawal benefit.

D.A S.S A.A.O

Paid by inclusion in Cheque No date vide Cheque BookAccount No 10 Debit Item No

D.A S.S AC (CASH)

For issues of S.S :IDS is enclosed

D.A S.S APFC (A/CS)

(FOR USE IN PENISION SECTION)

Scheme Certificate bearing the control no Issued on and entered in the scheme certificate control register

D.A S.S APFC (Pension)