form 19 & 10c epf
TRANSCRIPT
'::J;j~'-I' :;~c; -:~':...:-..;'::;":::5:I (NI~~I.j -;{. a~~~;50.Regn.,No.66~~ 19:;' ~.19i. ""'. .
" . fORM 19. .
.e~~ID~ ~~~f$~~li;~~~, ;J;9~<:::;;~~fufu~~q~~
EMPLOYEES' PROVIDENT FUND SCHEME, 1952'''\
f1Jt)dsKJeJ&fa)~:041QjLD~nfueJiJ;illaillJ~&fis(jJ~\ ~41:Oamo1SJro~@QjOlJiJf')o~ tj~&ru~ roJ[J()-72 (5))Cfi.~.-R.WI m ~Cqn 72(5)) ~4~ID<qff.f~m~-P:ft~-;n52~ ~ ~"fflT ~ ~ ~ l:fiTtf
FORM TO BE USED BY MAJOR MEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME '52."FOR
CLAIMING THE EMPLOYEES' PRQVID~NT FUND DUE lPARA 72-(5)] I Employee- .--'--'(() ,
Employe(~~-w~~ ~e!o-WoQ pqm3r¥~r~ Refer to INSTRlJCTIONS
1. :0~P tb.J (:Je :Je ~~0'C)6')
.~ Cf)T~ (~31oo iT)Name of the member (in Block Letters)
a) "'°(9 tb.J I~ Cf)T ~ I Father's Name
b) <;5~tb.J I 1:ffu Cf)T~ I Husband's Name
.Ri;Jx6-'i ;04b~G ';),:,);3;,;);;)'iO'~lI"b;Jx / ;00:--,;) ;:)b.J.;)";Jj>
Cf1TH§HT l'f~ ~ ~ C!1rar,fuWt ~ 3'ifuQ qr{~'mName& Addres>iof the FactoryI Establishmentin which the memberwas last employed.
$"Ei" :~o.. ~0" ;00<;P~/ ~ 'B., '@1(ff'B.C0de No., Account No.
2,
3.
. 4.
5, .t5'Si\:;):.) ;Ji:)v:~ 06 / ~ ~ c8~ I DateofLeavingService:
6. G5'Si\~ ;Si:)iD;;)~bc.>;Jx ~ ~ Cf)T ~ I Reason for Leaving Service:
~/ ~;:).;)<.iJ/Sv~5/.m/ ~ I~ I Sri/Smt/Kumari ....
TT jqr;ft l:rft S/o. W/o. 0/0. , , .." ...". ........
~6~.:o e.:>~0'<:)5"~e ;:)b.;),:y;Jj>
Full Postal Address(in Block Letters) .' ,... ...". , , , ....
.,...,'...,..,."..".,., , "..:: ,...,..., "..., , , ',""'''''''''''''''''''''''''''''''''''''''''' fi:R/ Pin... ..\., ,.....
;7~~ ;Sgo~;J<:);,;),~;)i;);k ~~6' =~;;),';)g<.iJi! r~~0o~a;;).;). i:f1G!..f c8 fc!fu~ f<tm ~..~ I:f{~ iT(fV:!»~Mode of remittance Put a tick in the box against theqne opted
a) ,:y<;pb.;)j5'"'~<:);:).;)~o'5.J>gw"'jO'~;;' 7 S~Wll" =~;;,~w.;)"~ / ift:~ I:f{11it WJ\ IDU"R..B'&n 7it ~:rrq~~ TJit~ I:f{
By postal moneyorderat my cost to the addressgivenagainstitemNO.7: r / I
b) ,'3'~ <3VM~b.J;~.;)" ~;)of;' <J'$OSv~<iJ'5" (~~$...6 <J'.,SoSv~.s.) ~~ 'i~Q~3:5W"'i" ~07: ~)~ow~o.:.;, '3SvI:-W'j0'
~~~~ijhFm'@1(ffR,iI~~~(~~/~;mm~"~) I IBy Account Payee Cheque I through Electronic C!E)~ralJceSys,tem (ECS) sent c':ect '.
for credit to my S.B. Ale. Scheduled Bank I Post Office) under intimation:
2.?~0!:i; ~w/ ~ Cf)T ~ I Name of the Bank ;, """',''''''''''''''''''''''''''''''''''''''''
.J":;P / ~ I Branch : """""""""'::.""'" :.:: \: .."..,
..)S.iJ."'~oS:5o./~ ~ '@1(ff-;{./S.B. Account N()
7.
8.
S.B, Ale. No.in words
.J":;P~~ ;:)b.;).;)";Jj> I ~ Cf)T~ -q(i[ttR ~ ~ I Full Address of the Branch
'lo~ ~owo,:)~~~lI" ~jc:j~~ ~;Sj~O/,~ ~ mR ~ eftTltfAdvanceStamped f1eceiptfurni~hedbeI0w.. .
.II~-_.,~--
--'--'-'
-- ~Pin Code :~.._._-
~6.Jfu~~J..~o.~ go°L~~ .s~~, """":,w:,.w"""",::",~,,:,~",,,, """".'<
CONTRIBUTION FOR, THE CURRENT FINANCIAL. YEAR
3i~I~I'" / Statytory Rate of
'Contribotjons :,.:,V"",\'"
10% 1\2%-,-~ , R" ' j
,:.~
, == ~I~,
111==,
-'--" .""...,.",~ ""0(' "',' "'0(' ..q''''M''~
.. WORKER'S SHARE EMPLOYER'S SHARE ~qa ..f.=>ri\Wii~tf1':'4 :wrl'q(~~..,
1f11! ~'mn j ,".c:;. ,:,,' "'i;'q;.~..~i mtr'f.tfu~ ,itfft)/ 3f'l.~'Cfil.'q.''1.j ~~-r.rm j. period of
M h EPF difference Pension Fund Ref. of . Remarksont Amount of EPF 10%& Contribution Advance ;?;r
Wages '8.'/,'10 or 12./~ & 8-1/3% No. of iJays( con n .u 1098'/ % servIce
, ~~ ~~1 2 3 4 4b 5 6 7
March paid in ',-\ ' ,', -'0,."
Aprilj1fT'ii 'o/T ~~ "-- - -- (a) -:fIcntT~~ ~~
;;p IJune f.ffu ~--~ -- ~m;it~ /July Dateof
~ leaving-~1lT({.!Aug~- service, if
~ 1 September any.-- -
~y-n 1 October --,--
;pj1."iif1:/ November
~ I December ~ - (b) ~, ~q;f
~ojcl~ I_~_anuary , <nroJT <i'fu
'PCIil I Februarv ---~-- ~ m ;it-- : :._- 1 -- Reasonsl:f;<.-.::rR)Ii '1'['1/ for
February paid in Marcil "4" leaving-" service. if
¥'I/ TOTAL any.
FORM No. 5
FORI~~'N9. 10'
A/c.~o. Name of the employee(in Block Letters)
Father Name(or Husb,and's Name incase of married women
Date Qfleaving ,
ServiceReason of
LeavingServiceRemarks
~.'
Date:~wpr 3!1~.ctIl(I~~'~:I~ !"' /,:~~14'1~.~ ~
Signature of Authorised Official: Seal;bfthe' Establishment~
Remarks:Date of
Total period of PreviousAle.eligibility for previous No.and
particulars ofnew member I servicepreviousFather Name
Date of date of joining (exclusing employer,anyName of the employee (or Husband's Name BirthSex t/)eEstt. in' It period of, (ifso whether,
A/c.No.(in Block Letters) in case of married cseot'old"
breaks) as on he is a memberwomen member the date of of familyjoining fund Pension Fund, .
aiso)
.
I'
-it ef->.[ITt :r m * ~DECLARATION OF NON~EMPLOYMENT
11~ CRCn~fc!;1f.t~ ~ft<n~([211 ~ f.rf4\Tfucfit31Rfqqm:fi %\1311ifi8,{;TW'9.fB "frmm ~cf2 1110cfit~q ifM ~ ~P'H'FITit ~ ~fCrRrf.'rft!31R~ ~ it. q;m~ R;qr~ I ,
Ideclare thai Ihave resigned and not employed)n any factory/ establishment to whichthe E,P.F.Scheme applies forH)f"continuous period of not les's than 2 rr,onths immediately preceding the data of my application'for final withdrawalofi;lV provident fund money, "
~mm GrC11~ ~I~(JII/ DECLARATION FOR UCD CLAIMI further declare that I am a reaiclaiment and could not apply immediatlytill now due to my personal reasons.fj 31r11~ cg(jl' t fc!;if 01mft~ t 3fR if 0<.Jfif(fT!(fC\1RuTIB ~i8 (f0'fk! ~ HGt-:Ti '
;~Ou~~ ~Ci :JG:O: / ~,c ;SO):5"w;:\~~ ~If? /'JG,B:r1; 6«!T~ 7:fT<rru,/ ~, o!?T1; ~ q;] f.mRSi~Jnatureor Left / Fiight hand thumb impression of the member
91'1\ 0\ mH'1<\10erF\H 0111?J~lFn
,:;ob.;c.; ,:y' ')b;u ;>c<i:9~;i)j,,",,w / :5"w~ ~~~t5 j<'gVw.This applicant has signed /thuml: impressed before me.
f~::rir:fi j[)
Date
~m "~:o,3If~if;~&t'"'r""~'"", ", , '," ""
:;::,C) :::b::5wG,::5w
2.i;~~p & 6~S"'b:JJ~wc~ ~t;)zoO~o~~~
Signature of the e!T!pl()~~rq! <;!uthoriseg'official~ ~ ~"'~CJO;'~O<fu ~t5
Designation &Seal[",d :
3IfchdImFd Rlk / ~o~~ ~~so.:J ~o~m ~~ (J&,~ADVANCE STAMPED RECEIPT
(~~m 8 ('&) cfit ~TT if ft<n ~ I) ( 8 (f)) (;>~~ O:';:SJ;:S<:;o::i:.,),~)(to be furnished only in case of 8(b) above)
WR~Lf-'!,'&1i't41R1RR ~ <itxR.311 / :;Pi~.31f~ .' .,
':1.<101.<'\,'0,., "..."., ,...,..,,,,.. '" .:.,..'"". .iifi1~~'i:Rf'~ mm.'i~
,ieceived a sum of Rs, """"."".""." , (Rupe8s ".." only)iromFiegional Provident Fund Commissioner/Office-in-Charge of my Provident Fund Account'f deposit in my Savings Bank account towrd the settlement of my Provident Fund Account.
:;tim ~fJ-:rf.rfq ~ />r'l11D31f~ID\T ~ it; ~ ~ ;on~rI
t>c2c:i: .;5;J~,Dy>j,~~::5w/~ot>cili $;~zoO'0eJ~~~9~,y~Qo~W';v~~~) ;$C5eJ;sa~.,"
[he space should be left blank which shall be filled in by Regional Provident FundCommissioner / Officer-in-Charge.
1 ~CfiT~WR
~z..'ibv";J.= ro~$i');:;\;5)",,'::H~~"Affixe 1 Rup~eRevenue, Stamp!
RtfiC:'q"{~<r if; ~&« m ~/~ -m~if; Wr3"<filf-mFfSignature or Left fRight hand thumb impression of the member on the Revenue Stamp
..fICh~1it ";{m ~ . ~
FOR THE USE OF COMMISSIONER'S (OFFICE)
~'fJTl:f~. 9~24l{
-;:jR~11<IT
Fact of settlement noted in Form
NO.9and Form No. 24
Entered in withdrawal Register
~Clerk
31.l:T.
8.8.
R~.31.
AAOR'q.f.t.31T.
APFC
BmfT;i./:m.>T.
A/c.No.APIit "&)"qmUnder Rs. .............................................
"ffim-gq/A.G.--------------MO/Cheques
-q;ft~/~
I ~ 1Jfu~2t
Amount authorised Rs. '"'''''''''''''''''''''' ... , ...........
~ (Rupees. .,... """"'"'''' """""""'" , ;. )
2, 'f.'ftm ~
M.0. Commission.. .................
3. :p1(lRr.8~ cwfi~ 1JfuNet Amount Payable'Rs. """""'"'' ..........
4. 'IJ.If.RP.I. No.
~B.ScrollNo.
..~Date:
~.fR./P.C. ~.-R.31. /~.~.f.:t,an, / AAO/APFt
{I~s ~~.~ ~.~}!ili~~,(FOR USE INCASH'SECTION)
oo~ (~) @T(f[B.1
Paid by inclusion in.Cheque No.;""""">;"''''''''..'''''''''''''''''''''''''''''''''','''''''''''''';' @;;j,i<h LPate , .vide cash Book (Bank) Account No.1 Debit item No.
;:rrq~ B ~B @ojiCh ; if~'[TU ~~l'"«:f[.
'ff.rn.D.A.
3{;q,
S.S.~i~.f.t.an, / &t:3n,A.P.F.C./ R.P.F.C.
t
...,
90~ "UJSerial No.~~~ ~o: 10-~ CQ~~)
~-ri. 1a-m (~.tfi.~)
Form No. 10-C (E.RS.)
~O'"$eJ~ 6~~Ko ;J~~oct>1~1~~n<1~it~For Office Use only
Z1~oS~~O~$ / ~ ~/ Inward No.
iI
\
~~~6J~ ~OW~ ~~~O, 199~~ q~IGI~, 1995
BMPWYEES' PENSION SCUEME, 1995Ji.~~o~6ro ~~~~ ~~('.)J!~~o
L~~ ~~PJ. ~o&~~~o. Ji.c;;S!J~eJ~o-6~
~~o. 1995 t:S°16~~!J~ Ji.~aue>o-6~ ~6fuJ.
Ch4-q1.[\~~, 1995~~mrHChIt11~ I~~~IUIY~~'~ ~~CfiT~
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME, 1995
FO~ CLAIMING WITHDRAWAL BENEFIT I SCHEME CERTIFICATE
(~~~~~ £;6 ~1w ~O~ QO~~(O ~i.sn)~~ i.sGSQ)OQ), -»
(~~ eFt~ -B~ ~ eFt~~)I (Readthe instructionsbefore filling up this form)
1. oJ) ~r;5,JS;J i,~ (;)eo~~O'"eJ~)
Cfi) ~~ CfiT-;:rp:f
a) Name of the Member
(in Block Letters)
w) ~~~~~;J( eJ) i,t;.:.'@)~it-;:rp:f
b) Name of Claimant(s)
2 (a) ~~~ja /~~l Date of Birth[=rJ
c?~~ I Days
crJ~eJ / Month
c=o=rJ~o~~bo/ Year
.~.
(b) Marital Status
3. oJ) i$o~ ~~/r;5E, ~~ (;J~o.J~S)Cf) ) f'RrrCfiT1111/ crfu OI1T1111 (~ (VWl"8)
a) Father's Name / Husband's Name (if applicable)
4. ~~730. ~O~~~u-°~73o:CfiTs B&n wn-#mnB&n
~o~ ~w 730,~~u-°~ ~o / -#mnBr.9<1T,~~CfiTCfit? ~ /Estt. Code No., Alc No.
. Code No. & Account NQ, E/ .. J5. ~r;5,J$~ .J~oiJoO{\O~;J"3i.J~~o~ i,~, J~;:)"~
f~ CfiT -;:rp:f <Of11m ~ BiWT ~ it Cfi1<ffifit IName & Address of theEstablishment in which,
the merr:"'''r was last employed.1
..--.----------------.-
!~a). 3e~~E>~ ctIT mm
Date of Joining
6. ;60~OS;6~$~,so~oa~ ~a /Rfu-q~ ~ ctITmm:.Dateof membershipjoining the Fund
6(a) ;65,s;6J~oQ, ~S'~f\~o~~ ~~MO ~e~ ~S'~f\~ ~a :itcrr~;r q)f CfiWJT(1m ~ ;rctIT mm .
Reasonfor leavingservice & Date at leaving
7. ~§ ~~~ .:;)W~~ (:)Q, ~~~~OS)STCOq)f ~ 1R!T : .
(~31&ro ii)Full Postal address
(In Block Letters)
~/~~/~~em/sftmft/~(ShrilSmtlKum)
~~w~/~~/~~£~/~/~ .
Slo, Wlo, 0/0
~~;60~tiM ~03J0!::j~~ eJ~
~~~o ~~~~o ~of\~e~~?
'FfT3m. >rqlU1'Bf~ mmt ~ ~ ~ ~Are you willing to accept withdrawal benefitOR Scheme Certificate(Put a tick (v"') in the concerned box)~~O&) ;)~~~ t'<fJ"{jd~~ ~e~ ~~w, ~~~ t~)
-qfufT(if; fcr<Rur (cffir <IT'f(';f'r (1m ~ ~~)Particulars of Family (Spouse & Children & Nominee)
8.
9.
\
~5 ~~ ~o./ftR/PIN :
~~;6o~tiM ~03J0!::j~~mmt~
Withdrawal Benefit
D
~~~o ~~~~o.~Scheme Certificate
D
~~ l;:wr I Name
-"
~~;::)sa~ fctfu
Date of Birth
'::>~i?& ~~~ '::>oo~~ ~.J1"f1~ct>if; m:~
q)f ;rrqNameof the
guardianof Minor
oJ) ~:x,'b/ ~ I Nominee
{)) ~W02J. ~~S<W
q; ) <rftcm:BGflI.a) Family Members
l'ie:> '::>02J0,;50
~ it B<siqRelationshipwith member
,
..
2
o. ~Q..).;)~~~:?~ ~~o.> ~~~ ~oa 58 ~~o-~;S~ 'o-~~ ~~~~~ ~t!~~ ~ol8S~J°5' :58~ ctT~ c);~ -en~ 'en)~ fuRnm:<fC6t~~ -en':Incase of death of member afterattainingthe age of,58 years~withoutfilingthe claim:
) :':::;5"$~~(;jcl o,:).~~o / ~ ct1~ ct1f'afu/ Dateof deathof the member:
) t~O"~::J( <:)t~/~~"S<:)~ X<:)~oZJot;Jr:/~c);~ I i'fi.tT~~~m /Name of the Claimants(s) i and relationship willithe members:
1. 3go~o :)'7~o (~~ ~O~ :.x3~ ~ ~~~ W~lr'( tf) r~~~~o~.~CfiT~T (mc;qc); ~~~c); 31PTR-Cfi~)
MODEOF REMITTANCE(PUTATICK( tf) INTHE BOr<AGAINSTTHE ONEOPTED)
;) ~o. 7;:) UO'dO@o~ '1,)~ ,:)~.;J"~~.;J" ~~o~ u;yO ~;:). E:;:Jg~O"jO".Cfi) 11G~ 7c);31Pt~ ~ "R~ ~ 'ij1:1TRtYf-q;fi~<~"&m :
a) By postal moneyorder at mycost the addressgivenagainstitem No,7
D) ~~$o.> ~$O!;N~~ ~:)o~ ~$O~ e.:is'lr°W,j~O~,) ~~~~$
.;J"!;N<J~M~~~ "~S"lr°W,j ~Wo.)3~lr;$J" ~o~~.\9) ~~Cfi\it~~~t~~~WOT~6rffiC);
~~<fi)~~~~~
b) Accountpayeechequesentdirectfor credit to my SB Alc (ScheduleBank)Under intimationto me.
.:J5.D.e.;s"lrWJ~OW~.~~ ~ ~I S.B,AccountNo.
~$O!;N ~ (~~ c':)~O"o~)~ <fiT~ (~' ~~~)
Name of the Bank (in block letters)
oi1"~~~ (:)~ e"~O"o~)mm / Branch (in block letters)
.~~ ~~ lr ~~ :>~.;J"~~CfiTWlqm (~ ~1ffiT~)Full Address of the Branch
c) ~6 ~~osoK ;;J~c1P00$00~ t:>oKJ 2J"~~ ~ Jo~~§ ~~qiR~ ~ B-q{~ ~ ~ ~~ct>~If.tct>IDD~
Bv ElectronicCredit in my S.B.Account throughCore BankingSystem,
12~~''1~J~, 1995 @oc.':S~~ ~~ ~o~JO" ?C,:)Wo.)~~;5O"o.>~w~o~.
~:mq~~~, 1995c);~~~\%~ I
CJ
Are you availing pension under EPF 95 ?
31Trc~m~ <fi{ ~2... ~o./ifi.ifi.31T. ~/PPO No.
If so, indica1e : ;);50 ~Ow ~O jM~~~<5/~ IDtt / By whom !ssued
~~ ~i->~6:)6~ ~~ ~~~ ~~e.> 'd»86~~ I~:>~OO~~{~."- (j) "- l: ok
~"'IUI@ ~~~'fcn~~~ ~ \lf1-1~I{\~ ~~~,CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY K~OWLEDGE
a<5~ /D~te: ~oU!fQaO"~~S';)!$.~fS:J;:) (;;)
J~~ 3t) 5"~ ~~ ~~~ /~$~~-qy~m~~~C6Tf.mR
Signature or Left.Hand Thumb impression of the Member I Claimants(s)
1YJ'C3iI~'LiiJilOqg'tf.e~ .. ~.-;) " eJ
~~ft~ I ADVANCE"STAMPEDRECEIPT
(~;;) ~e5~;;) (,';)) e90~O :J~dS.)o~ ~~~ i}e?dS.>~dS.>~e>~~t))o~) / {-:S4(1ttO(~) c€tGm
if 1ft)1'Pffi~ ) / (To be furnished only in case of (b) above)
~~ ~oZ)ot;J~;5 ~o~ ~o~ ~S'lr°~ ~WelaOW~c\i)oef ~:>o~ 2J'$O~ ~S'lr°~ef c;J.~w.; 3M'?0 ~.s~~ob~ i;5~;Jt;J~:>Jo~/ ~e-°bMS"'~$~c\i)O 9~~ ~t;JS"'c~oc~ ,..--------
(b.Y~o'5Jw ~.~~~6' ~ ' ) ~.s~C~~<5.~'-_. (itcrct
. - wr)~ ~f.Ifu ~ / ~ ~~it mntt~wu~~f.@nmitit f.t1R:~it <i>RUTm ~ ~ @it ihmr it ~ 1)meaf<8n I
Received a sum of Rs. ( Rupees
only from Regional Provident Fund Commisioner / Officer-in-charge 01Sub-Regional Office
by deposit in my savings Bank Nc towards the settlement of my Pension Fund Account.
~ObM i;5:>~;)t;J~~~bJ / e.s~bJ9~>7~~ o~~ ~b;J ~.¥~~.(W~citwrBt~W ftm~~f.Ifu~ /~~IDU~~)(The space should be left blankwhich shall be filled by Regional Pravdent Fund Commissioner / Officer-in-charge).
~o~2 ~i;5~~;)~b~~o e§~. ')~~3& ~~;:S ~~~~. '
I
' RS.1/- IQCfi'Z':rn1<;B!it ~1!3{<n qpt~it ~ CfiTf.mR Revenue
Signatureor LeftHandThumbImpressionof the memberon the stamp, Stamp
~i;5J~~ O~o'5J~u~;:S;)~~w'o'5JO"~;:S~;) ~Cc\i)J ;J"~~~o6" ~~;:5J~o~~o ~~~~ ~~~ <;S.)~~C~~;:S<5.WfliUm fcri<n "ITill~fcn~ IDUfu!;1TTJ:~UT ~~ 3fu:"3W ~.OO ~ ~ ~ / ~ CfiTf.mR wn<n% I .
Certified that the particulars of the member given are correct and the member has signed I thumb impressed before me.
"ju~~ ;)~~o.; ~i;5J0~ ;)~vo ~~o.;;5;) ~a.s~S"'~~ ;)~~W ~ ~oa ;)?>OIP 6~JOJJ.
~7fm~it ~~:tIl<14)Wnit"fucro1r~~~:
The details of wages and period of non-cont~ibutoiy service of the member are as under:
GSi;1\~~ i;5;)~;)t;J S"'~~~~;Js ~o~;J S"'eJ";)s x~ ~~;:5J ;:S~;J"~O&)UJ 3::/7 zP~ z;w~.:s~;:sa.
(18lf 3 Cfi/7 (t<ft.~.)~~CfiT~t ~~<!>T~~f.Ifu~q;)11ffi't~1TTJ:~)(Form 3 A / 7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund Office)
~6\~ ~t)0 ~v;:s ~8 ;J1'ws jl1§;J1'D)~ M
~ ts:;r <tIfufucfr~Wages as on the date of exit I leaving ,
~]5-]]-95CfiT~ (l@ ~ + ~~~) (WR"Rf1Lm)Wages (Basic + DA) as on 15-11-95 (if applicable)
~V"v 0 "300.;;5;)~6\~ ~e;oM ~
~ircn<tl ~
~ /
Period of Non-contributory Service (Breaks in Service) ,
~~~~Ju0 ~~C?1 g<:f /_liNl Year / Month
5" ~~~o~~ R;fLcfr<ci~IL No. ()f DaysParticulars of Breaks month-wise should be furnished in
a separate statement Le. From Date of Joining to15-11-1995 & 16-11-1995 to Date of Leaving Service.
D.O.J. to 15-11-1995
~16-11-1995 to D.O.L.
..
4.
~O@o'5J~;J / ~~~)~ ~t;J~C ~O.u~O
~/~<h~~I~~~1
Signature of Employer I Authorised Officialof th~ Estt.with Seal & Date
C~~~~~ -ggCQ.)~~O ~~~CP~O)(~it ct11~IM~it ~Y~I~Iit~)
(FOR THE USE OF COMMISSIONER'S OFFICE)
(w. --~----- o~~o~o) ~.8J";;)0: ~Y'J ~g~ lZ';;'JJ/;-WOjO".
0 ~i§o "3Do~~ ~o~~ ;3M~;:sa.~ M ~
w. ( C;:J~O"oot )~ 3=R\ I~lTc:~ 1=[;fi 3TT6c<: / ~ mu.
(31~if)
<!.----
~ 'TIcfR~~1
Ale. No. API
(Under Rs._- M.a. / Cheque.
Passed for payment for Rs.
(in words) Rupees
~;') ~b~ ~~~,.~ ~a;:s~'od w.co ""'"< ~ '<::.i 6~~0~br? ~03J"2;;;:S0~0 ;)0. LwojO" "3go~;:SXJ ~~b~00-"'
11iT 3TT6c{Cfimm- (0'PR;m)
M O. Commissioner (if any)
11-fi3TT6c{mu ~ ~ \rfu
--- net amount to be paid by M.a. towards withdrawal benefit.
PI No. Scrotl No. Date:
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. (~ 3fj"1ll'T'it~ ~ ~)(FOR USE IN CA~ -:iECTION)
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Paid by inclusion in Cheque No. -Account No.1 0 Debit Item No.
Dt. vide Cash Book (Bank)
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Scheme Certificate bearing the control No. issued on and
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