Submitted online at Member e-seva portal on 2026-04-17 14:40:18 (IP [Link].
in
Address:[Link])
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 Member Portal and UAN has been activated.)
Mobile Number / eksckby uacj - 9369262787
Tracking ID : 10208183818901001
1. I want to apply for PF Final Settlement
2. Universal Account Number(UAN) / ;wfuolZy [kkrk la[;k 102081838189
3. Name of the member SRISHTI MAURYA
4. Date of Joining 13-May-2024
5. Date of Leaving Service/ NksM+us dk fnukad 22-Jan-2026
6. Reason of Leaving Service/ lsok NksM+us dk dkj.k CESSATION (SHORT SERVICE) - Any other
reason
7. Permanent Account number / LFkk;h [kkrk la[;k HABPM9068N
8. is Form-121 uploaded ? No
9. Payee Address 145, Gopalapur Chaura mata
mandir,Jaunpur,JAUNPUR,UTTAR
PRADESH-222001
* eSa ç[Link] djrk gw¡ fd eSaus ;w , ,u iksVZy ij lhM MkVk dks Hkyh Hkk¡fr ns[k fy;k gS rFkk QkeZ u- 11( u;k ) cSad [kkrk fooj.k vkSj vk/kkj
la[;k lfgr lHkh MkVk lgh ik;k x;k gSA
* I certify that I have gone through the data seeded in Member Portal and found all data including Form
No.11 (New) , bank account details and Aadhar Number to be correct
Father/Husband/Spouse Name: AMIT KUMAR MAURYA Date Of Birth: 07-Aug-2001
Bank Account Number 031401583968 Bank IFSC Code ICIC0000314
Bank Details ICICI BANK LIMITED,GURGAON - SUSHANT LOK
Aadhaar 80XXXXXXXX97
Member ID GNGGN16477190000010674
* —i;k ;w-,-,u-iksVZy ij n'kkZ, x, cSad [kkrs esa Hkqxrku djsaA
* Please make payment in the bank account mentioned in the Member portal .
* The bank kyc has been online verified by bank and has been digitally signed by the employer for this case among
other validations and therefore mandatory uploading of the image of cheque leaf/attested bank passbook is not
required.