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Form-10C

Form-10C

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Published by Keshav Mishra

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Categories:Types, Legal forms
Published by: Keshav Mishra on Jun 05, 2010
Copyright:Attribution Non-commercial

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05/16/2011

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FORM No. 10 - C (E.P.S.)
EMPLOYEE'S PENSION SCHEME - 1995
Inward No:
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME 1995 FORCLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
1 (a)(b)
Name of the claimant(s)
2
Date of Birth
3 (a)
Father's Name
(b)
Husband's Name (if applicable)
4Name and address of the Establishmentin which, the member was last employed5
Code No. & Account No.
RO/SRO CodeEstt Code No.A/c No.6
Reasons for leaving Services
Resigned
& Date of Leaving
7Full Postal Address (in Block Letters)Sri / Smt. / Kum.S/o. / D/o. / H/o. / W/o.PIN :8Are you willing to accept Scheme(a) Yes (b) NoCertificate in lieu of Withdrawal Benefits ?9Particulars of Family(Spouse,children or NomineeName Date of BirthRelationshipName of thewith the memberguardian of mino(a) Family member/(s)(
Read the instruction before filling of this form)
Name of the member 
(in Block Letters)
 
(b) Nominee10Incase of death of the member after the age of 58 years without filing the claim :(a) Date of death of the membe(b) Name of the claimant(s) andrelationship with the member 11
MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ON OPTED)
(a)By postal money order at my cost tothe address given against column No.7(b) Account payee cheque sent direct for credit to my S.B.A/c (scheduled bank)under Intimation to me.S.B A/C NoECS Code No.Name of the bank(in block letters)Branch(in block letters)Full postal address of the Branch(in block letters)PIN12Are you availing pension under EPS-1995 if so,indicatePPO Noby whom issued
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
DateSignature/Left hand thumb impression of the Member/cliamant(s)
ADVANCED STAMPED RECEIPT
(To be furnished only in case of 11(b) above)Received a sum of Rs _____________________(Rupees________________________________ only)from the Regional PF Commissioner/officer-in-Charge of Sub-regional Office, by depositing in savings Bank A/ctowards the settlement of my Pension Fund account.The space should be left blank which shall be filled by this office. Affix Rs 1Revenuestamp
 
Signature/left hand thumb impression of the member on the

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