DECLARATION

To,

Date:______________

The Regional PF Commissioner

SRO, K R Puram
Bangalore
Sub: Declaration regarding not being a PF member at present-reg.
Sir,
I, hereby certify that I am not employed in any establishment which is covered under PF Act and
that I am not an EPF member. I request that my application for withdrawal i.e. Form-19 and Form10C may please be processed. I have also enclosed KYC documents like Aadhar/PAN/Bank
Account number etc. along with the application.
Yours faithfully

Sign:_____________________
Name:_____________________
PF Code Number:____________________
UAN:_____________________