Form 19 - Employees Provident Fund Scheme (Page 5 of 5) in pdf

declaration of non-employment in the application should be completed

duly dated.

The claim application should be attested and forwarded by the employer

under whom the member was last employed.

If the member is unable to send the applicatin through the employer or

duly attested by him for and reason whatsoever he may forward the claims

duly signed in the presence of any one of the following authorised and got

attested over his official seal.

(i)Magistrate; (ii) A Gazetted Officer; (*iii) Post / Sub-Postmaster; (Iv)

President of the Village Union; (v) President of the Village Panchayat

where if no Union Board; (vi) Chairman/Secretary/Member of the

Municipal/District Local Board; (vii) Member of Parliament/-Legislative

Assembly; (viii) Member of Central Board of Trustees/Regional Committes

Employees’ Provident Fund; (ix) Manager of the Bank in which the

Savings Bank Account is maintained; (x) Head of any recognised

educational institution; (xi) any authorised person as may be approved by

the Commissioner.

The following documents 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 covered under The ESI Scheme the Medical Officer

designated by the Establishment should be attached.

In case of migration from India for permanent settlement abroad Visa,

Passport, Journey ticket etc., should be sent for perusal and return.

The member should also furnish the address in the acknowledgement

card attached to the claim(s).

10.

Instructions to the employer before forwarding the claims.

Details of contribution in respect of the member for the current financial

year should be furnished in the certificate portion, in case, the contribution

is not already paid it should be remitted by separate challan and receipted

triplicate challan should be enclosed to the claim.

11.

In support of claim under Employees’ Family Pension Scheme, 71 the

period of break in reckonable service (i.e. period for which EPF

contribution is not payable) should be furnished if not already intimated

through contribution card.

Note : If claim in Form 10-B EPF) along preferred S. Nos. 2,6 & 8 are not

applicable.

Form 19 - Employees Provident Fund Scheme Page 5