P.F. Claim Form

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

5:


2/6

;fror

Evaluation

Only.

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by

VeryPDF.com

Inc

Edited

by

VeryPDF

PDF

Editor

Version

2.6

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


3/6

- l':or

lSvaluabon

Only.

Copyriglrt

(


4/6


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)


6/6

.:

.

DOCU

MENTS

REQUINE

TbN

WiTHDRAVfAL

bF

P;F AI'IOUNT

t

aPPoINMENT

TETTER (CANDTDAIE)

'

2

REsrcNrrrrrnlcal.iOronrrl

3

RESIGN

A@?Tt\r.rCE

I,ETTER

(r{R)

4

P/iNCARD(CANDIDATE)

.

s

roRr{ 16

(E\ERyYEAR)

(CANDIDATE

A@rrNr)

6

(II,ARANCE

CERIFICATE(CAT.TDIDATE)

7

qTEQUE

(CAI.{GLXCANDTDATE)

8 PASS

B OOK B'ANi((CAI.{DIDATE)

9

CO\IERING

I-ETTER(CAI.{DIDATE)

10 DATE

OF BIRII{(CAI.{DIDATE)

Documents

P.F. Claim Form