www.epfindia.gov.

in
Mobile No 9257746420

EMPLOYEE'S PROVIDENT FUNDS ORGANISATION

COMPOSITE CLAIM FORM (AADHAR)

(APPLICABLE IN CASES WHERE EMPLOYEE'S COMPLETE DETAILS IN FORM-11(NEW),AADHAR NUMBER AND BANK ACCOUNT DETAILS ARE AVAILABLE ON UAN
PORTAL AND UAN HAS BEEN ACTIVATED)

[ FORM NO-19(PF FINAL SETTLEMENT)/10C(PENSION WITHDRAWAL BENEFITS)/31(PF PART WITHDRAWAL)]

1 Claim Applied For : i) Final PF Settlement ( √ ) ii) Pension Withdrawal Benefits (√ ) iii) PF Part Withdrawal ( )
(Tick Whichever Is/Are Applicable)
2 Name of the member : ( IN CAPITAL LETTERS) GANESH SALVI
3 Universal Account Number (UAN) 100663166239
4 Aadhar Number : 892349887635
5 Date Of Joining The Establishment : 2-Dec-14
6 a) Purpose Of PF Part Withdrawal :(Tick √ Whichever Applicable)
SN Purpose Of PF Part Withdrawal √
i Housing Loan/Purchase of Site/House/Flat
b) Amount (In RS) : or for Construction/Addition, Alteration in
existing House/Repayment Of Housing Loan
(Para 68B/68BB/68BC)
c) For Purpose Of Site/House/Flat Or Construction Through "Agency" Or ii Lockout or Closure Of Factory (Para 68H)
Repayment Of Housing Loan Or LIC, Indicate Cheque To Be Drawn iii illness of Member/Family (Para 68J)
"In Favour Of" And Payee's Address. iv Marriage of Self/Son/Daughter/Brother/
Sister ( Para 68K)
v Post Maticulation Education Of Children (Para
68K)
vi Natural Calamity (Para 68L)
vii Cut In Electricity In Establishment (Para 68M)
viii Purchasing Equipment By Physically
Handicapped (Para 68N)
ix One Year Before Retirement (Para 68NN)
x Investment In Varishta Pension Bima Yojna
(Para 68NNN)

7 Date Of Leaving Service : ( Not Required If Applying For PF Part Withdrawal) 30-Nov-23
8 a)Permanent Account No.(PAN):(Only In Case Of Service Less Than 5 Years)
(Please Enclose two Copies Of Form No.15G/15H,If Applicable) 0

b)Reason Of Leaving Service:

* Service Terminated On Account Of (a) ill Health Of Member (b)
RESIGNATION
Contaction /Discontinuation Of Employer's Buisness ( c) Other
Cause Beyond The Control Of Member

* Personal Reasons

9 Full Postal Address aasha pura colony , ward no 34 City Udaipur

313003 State Rajasthan
udaipur
rajasthan Pin No : 303001

* Certified that the particulars are true to the best of knowldege. 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 Aadhar 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 accout number and IFSC code ) is
attached here with.

*In case the amount is used for any purpose other than stated in coloumn (6) above, I am liable to return the entire amount with penal
interest.

@
Member's Singnature
 "FORM NO. 15G
[See section 197A(1), 197A(1A) and rule 29C]

Declaration under section 197A(1) and section 197A(1A) of the Income ‐tax Act, 1961 to be made by n
individual or a person (not being a company or firm) claiming certain receipts without deduction of
tax.
PART I
1. Name of Assessee (Declarant) GANESH SALVI 2. PAN of the Assessee 0
3. Assessment Year
( for which declaration is being made)
4. Flat/Door/Block No. 5. Name of Premises 6. #Status
7. Assessed in which Ward/Circle NO
8. Road/Street/Lane 9. Area/Locality 10. AO Code (under whom
aasha pura colony , ward no 34 assessed last time
313003 Area Code AO Type Range Code AO No.
11. Town/City/District 12. State 13. PIN #REF!
#REF! #REF! 14. Last Assessment Year in which assessed
15. Email 16. Telephone No. (with STD Code) and Mobile No. 17. Present Ward/Circle NO
0 18. Residential Status ( within the
19. Name of Business/Occupation meaning of Section 6 of the Income NO
Tax Act,1961)

20. Present AO Code (if not same

as above) NO
21. Jurisdictional Chief Commissioner of Income‐tax or Commissioner of
Income‐tax (if not assessed to Income‐tax earlier) Area Code AO Type Range Code AO No.
NO
22. Estimated total income from the sources mentioned below:
(Please tick the relevant box)
Dividend from shares referred to in Schedule I NO
Interest on securities referred to in Schedule II NO
Interest on sums referred to in Schedule III NO
Income form units referred to in Schedule IV NO
The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to in ScheduleV NO
23. Estimated total income of the previous year in which income mentioned in Column 22 is to be included

24. Details of investments in respect of which the declaration is being made:

SCHEDULE‐I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)

No. of Class of shares & face value Total value Distinctive numbers Date(s) on which the shares were
shares of each share of shares of the shares acquired by the declarant (dd/mm/yyyy)
NO NO NO NO NO
NO NO NO NO NO

SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)

Description of Amount of Date(s) of securities Date(s) on which the securities were acquired
Number of securities
securities securities (dd/mm/yyyy) by the declarant (dd/mm/yyyy)
NO NO NO NO NO
NO NO NO NO NO

SCHEDULE‐III
(Details of the sums given by the declarant on interest)

Period for which

Name and address of the person to whom Amount of sums Date on which the sums were Rate of
sums were given on
the sums are given on interest given on interest given on interest(dd/mm/yyyy) interest
interest

NO NO NO NO NO
NO NO NO NO NO
 SCHEDULE‐IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)

Name and address of the Number of Class of units and face value Distinctive number of Income in respect of
mutual fund units of each unit units units
NO NO NO NO NO
NO NO NO NO NO

SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)

Date on which the The amount of

Particulars of the Post Office where the account under the National Savings Scheme is
account was withdrawal from the
maintained and the account number
opened(dd/mm/yyyy) account

NO NO NO

@
**Signature of the Declarant

Declaration/Verification
*I/We do hereby declare that to the best of *my/our knowledge and belief
what is stated above is correct, complete and is truly stated. *I/We declare that the incomes referred to in this form are not
includible in the total income of any other person u/s 60 to 64 of the Income‐tax Act, 1961. *I/We further, declare that the tax
*on my/our estimated total income, including *income/incomes referred to in Column 22 above, omputed in accordance with the
provisions of the Income‐tax Act, 1961, for the previous year ending on relevant to the assessment year
will not exceed the maximum amount which is not chargeable to income ‐tax.

Place:
@
Date: Signature of the Declarant

PART II
[For use by the person to whom the declaration is furnished]

1. Name of the person responsible for paying the income referred to in Column 22
2. PAN of the person indicated in Column 1 of Part II
of Part I

3. Complete Address 4. TAN of the person indicated in Column 1 of Part II

6. Telephone No. (with STD Code) and

5. Email 7. Status
Mobile No.
10. Amount of income
paid 11. Date on which the
9. Period in respect of which the dividend income has been
8. Date on which Declaration is paid/credited
has been declared or the income has been
Furnished (dd/mm/yyyy) (dd/mm/yyyy)
paid/credited

12. Date of declaration, distribution or payment of dividend/ withdrawal 13. Account Number of National Saving Scheme from which
under the National Savingscheme(dd/mm/yyyy) withdrawal has been made

Forwarded to the Chief Commissioner or Commissioner of Income‐tax

Place:
Date:
Signature of the person responsible for
paying the income referred to in
Column 22 of Part I
ESTABLISHMENT NAME & ADDRESS

MOBILE NO 9257746420
MEMBER NAME GANESH SALVI
UAN NO 100663166239
AADHAR NO 892349887635
DATE OF JOINING 2-Dec-14
DATE OF LEAVING 30-Nov-23
PAN NO
FULL POSTAL ADDRESS aasha pura colony , ward no 34

CITY 313003
STATE udaipur
PIN NO rajasthan