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    of 2

    Submitted online at UAN e-seva portal on 2024-09-28 19:35:38 (IP Address:27.4.43.25) www.epfindia.gov.

    in

    deZpkjh Hkfo"; fuf/k ;kstuk] 1952


    EMPLOYEES' PROVIDENT FUND SCHEME,1952
    EMPLOYEES' Pension Scheme,1995
    UAN Based Combined Claim Form 19/10C WB/31 for Advances/PF Final Settlement/Pension Fund Withdrawal
    (mu ekeyksa esa ykxw tgka QkeZ 11(u;k)esa deZpkjh dk iwjk fooj.k] vk/kkj la[;k vkSj cSad [kkrk la[;k ;w-,-,u- iksVZy vkSj ij
    miyC/k gS rFkk ;w-,-,u- esa lfØ; gSA)
    (Applicable in cases where employee's complete details in Form 11(New),Aadhaar Number and Bank
    Accounts details are available on UAN Portal and UAN has been activated.)
    Mobile Number / eksckby uacj - 8220929739
    1. I want to apply for PF Advance
    2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 101662417397
    3. Name of the member THAMIZHARASAN

    4. Date of Joining 26-Jul-2024


    5. Permanent Account number / LFkk;h [kkrk la[;k N.A.

    6.a Purpose of Advance Illness

    6.b Amount of Advance (In Rs) 9000


    7 In case of Advance for purpose of Site/House/Flat Not Applicable

    8 Bankers details for Electronic Payment (Only for the Advance if payable to Not Applicable
    third party)

    9. Payee Address NO. 117/02, SOUTH STREET


    VIZHAPPALLAM,
    UDAIYARPALAYAM,KATTATHUR,ARIYALUR,

    Father/Husband/Spouse Name: MINAR Date Of Birth: 20-Jun-1990


    Bank Account Number 500101013065220 Bank IFSC Code CIUB0000570
    Bank Details CITY UNION BANK LIMITED,CHENNAI VADAPALANI
    Aadhaar 61XXXXXXXX85
    Member ID DSNHP19956400000356542
    *Certified that the particulars are true to the best of my knowledge, I certify that I have gone through the data
    seeded in UAN portal and found all data, including Form No 11 (New), Bank Account details and Aadhaar number to
    be correct. Please make the payment in the bank account mentioned in the UAN Portal. A cancelled cheque
    (containing member's name, bank account number and IFS Code) is attached herewith. In case the amount is used for
    any purpose other than stated in column (6) above, I am liable to return the entire amount with penal interest.
    * —i;k ;w-,-,u-iksVZy ij n'kkZ, x, cSad [kkrs esa Hkqxrku djsaA
    * Please make payment in the bank account mentioned in the UAN portal .
    UAN - 101662417397 Tracking ID - 10166241739706002

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