wanw apidia gov in Matie Number EMPLOYEES’ PROVIDENT FUNDS ORGANISATION ‘COMPOSITE CLAIM FORM (NON-AADHAR) ‘Gaim applied Yor) Foal PF Setéement ( Tick whichever is/are applicable) V9) Persion Witierawal Benefis (—)_ Wi) PF PART WITHORAWAL (—} "Name of the member(IN CAPITAL LETTERS) a) Universal Account MuriberUAN) by PF. Account Non case UAN not avaiate) By bo ‘adhar Wumber (or seeding): 2) Father Hae: by Husbaras Name: we be ate oF Bie ‘Date of joining the establishment: Date of leaving sanica: (not required applying for PF Part Withcranal) {2} Permanent Account No PAN): (Only n case of sence Tes an 5 years) (Peace encase two copies of Farm No. 156/15H, f applicable) by Reason of leaving Service: ~ Service terminated on account of (a) lt heath of member (b) Contraction /Disconanuadon of empioyers busness er (e) Other Case boyend the contol ofthe member ~ Personal Reasons 0 2) Purpose of PF Part Wthdrawali(ik ¥ whichever apolicatie) 1b) Amount in Rs): ©) For purpose of steHouse/Fat or Construction through “agency” or Repayment of Housing Loan o LIC, indicate cheque to be craw = In fovour of” and payee's address. SR | “Purpose of PE Part withcrowal [7 T | Heusing Loan/Purchase of ste/House/fat or for Constructon/Adéition, alteration in exiting house/Repayment of Housing oan (Para 636/6688/608C) Lockout or closure of factory (Para 63H) Blness of membe/ramly (Para 68) ‘Mariage of selfson/daughter orate” (Para 684) V [Post Maticustion education of chides (Para 68x) | Natural calamity (Para 681) ‘Gut in electcty in establchment (Para eam Acvenice for Physically handeappea (Para con) vr Cne year efere reverent (Para GON) [Investment in Varsha Penson BiraYojaa (Para SENN) 7 ene Account deals Tor parents (Please tach copy of cancelled creque/atested copy of frst page of ass Book) Saving Bark Recount No, Names cares of the Bank @ Fal Pasa scares “Te member hereby declares that he has rot been employed fortwo mens (ea/No}) (Cotte that the particulars ae tue to thebestof my knowledge. In case the amount is Used for any purpose other than stated in column (10) above, 1 am liable to return the entire amourt with penal interest. Member's Signature Empoyers Signature Designaton® Seal of EmployerINSTRUCTION SHEET FOR FILLING THE COMPOSITE CLAIM FORM (NON-AADHAR) 1. Purpose of advance & documents required: (The purpose may be one of the following): ') Housing Loan/Purchase of site/house/fiat or for construction/Addition alteration in existing house/ Repayment of Housing loan: No document is required. New Declaration Form/Utiization Certificate required earlier has been discontinued, 1) Mines of member family: ') Certficate of doctor and ii) Certificate by employer that ESIC fecilty is ‘not available to the member may be submitted by the member. li) Marriage of setf/son/daughter /brother/sister: No document/Marriage Card is required. 'v) Post Matriculation education of children: No document is required. ¥) Lockout or closure of factory/Cut in supply of electricity: No document is required vi) Natural calamity: No document is required, wil) Purchasing equipment by physically handicapped: Medical certificate is required. vill) One year before retirement: 90% of total PF balance can be withdrawn. No document is required. '&) Investment in Varistha Pension Bima Yojana: 90% of total PF balance can be transferred to LIC. No ‘document is required 2, No Revenue stamp (Re. 1/-) is required to be affixed by the member. 3. Income Tax (TDS) is deducted ifthe service is less than 5 years (60 months). No Income Tax (TDS) is deducted in ase the total balance is less than Rs. 50,000/-. However, TDS is deducted @10% if the member submits PAN in such cases. In case PAN is not submited, then TDS @34.608% fs deducted. ‘The total service in the present establishment as well as previous establishment is counted and, therefore, it is advisable to merge all PF accounts. 5. Pension Withdrawal benefits can be availed only if the service is less than 10 years.