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Mobile No 0

EMPLOYEE'S PROVIDENT FUNDS ORGANISATION

COMPOSITE CLAIM FORM (NON-AADHAR)

[ 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) 0
3 a) Universal Account Number (UAN) 0
b) P.F. Account No.(In Case Uan Not Available)
4 Aadhar Number (For Seeding): 0
5 a) Father's Name : 0
b) Husband's Name : 0
6 Date Of Birth : 12/30/1899
7 Date Of Joining The Establishment : 30-Dec-99
8 Date Of Leaving Service : ( Not Required If Applying For PF Part Withdrawal) 30-Dec-99
9 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)

b)Reason Of Leaving Service:

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

* Personal Reasons

10 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)

11 Bank Account Details For Payment : Saving Bank Account No 0

Bank Name 0
Bank Address 0
(Please attach a copy of cancelled cheque/attested copy of first page of pass
book )
Pin No : 0
12 Full Postal Address 0 IFSC CODE 0

Pin No : 0

*The member hereby declares that he has not been employed for two months (Yes/No)
*Certified that the particulars are true to the best of my knowledge
*In case the amount is used for any purpose other than stated in coloumn (10) above, I am liable to return the entire amount with penal
interest.

Member's Singnature Employer's Signature

Designation & Seal Of Employer
@ @
 "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) 0 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
0 assessed last time
Area Code AO Type Range Code AO No.
11. Town/City/District 12. State 13. PIN 0
0 0 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 BARBEQUE-NATION HOSPITALITY LTD.
UG-5,SAYAJI PLAZA,H-1,SCHEME NO. 54
VIJAY NAGAR, INDORE - 452010

MOBILE NO
NAME
UAN NO
PF NO
AADHAR NO
FATHERS NAME
HUSBAND ( IF APPLICABLE)
DATE OF BIRTH
DATE OF JOINING
DATE OF LEAVING
BANK A/C NO
IFSC CODE
BANK NAME
BANK ADDRESS
PIN NO

FULL POSTAL ADDRESS

PIN NO
CITY
STATE

PAN NO