AFFIDAVIT-CUM-INDEMNITY BOND Passport Size Photo (Sign on the photo) I._____________________________ (Block letter) S/o, D/o, w/o _____________________________________________ Residing at: - Permanent Address: - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------___________________________________________ ___________________________________________ Taluk ___________District______________________ State ___________________Pin Code ____________ Phone Number:_______________________________ E-mail Id: _______________________________ Solemnly affirm and state on oath as under:1. I state I was an employee with (Name & Full Address of Establishment) is From _______________to ____________and holding P.F Account No. _______________________ with REGIONAL PROVIDENT FUND COMMISSIONER, (PF Office address) ______________________________________________________________________________________________________ _______________________________________________________________________and DECLARE that I am the Actual Provident Fund Account holder. 2. I am herewith submitting PF Claim Forms 19 / 10c / 13 and I hereby undertake an indemnity to Central Board of Trustees Employee’s Provided Fund Organization, Ministry of Labour, Government of India that this claim if later found false, I shall be responsible for any loss incurred out of this transaction. 3. I declare that I have NOT withdrawn / transferred my PF Accumulation / withdrawal benefit of FPF 1971 / Employee’s Pension Scheme’1995 till date (dated ________________) in respect of my above account. This Affidavit-cum-Indemnity Bond has been executed by me and state that the facts mentioned therein are true and correct. Solemnly affirmed / identified and signed before me On this day of ______________ Deponent (NAME) ADVOCATE (With seal) Identified / Witness (2 Nos.): Name & Address /Contact No . BEFORE ME (1ST Class Judicial Magistrate / Public Notary) (With seal) IDENTIFIED BY:In support of proof of Identify I am self attesting duly attested by notary / Gazetted Officer the following documents  1. PAN Card 2. Appointment letter issued by the company / pay slip  Date: Place: 3. Passport / Election Card 4. Bank pass book with address, latest signature attested by the bank manager