eksckby la-@ Mobile Number

¼dsoy dk;kZYk; ds iz;ksxkFkZ½@ For Office Use Only
nkok la[;k@Clam I.D. …………………….....................

fudklh ifjYkkHk@;kstuk izek.ki= ds nkos gsrq iz;ksx fd;k tkus okyk izi= 10 lh
FORM 10C FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
deZpkjh is”a ku ;kstuk] 1995 EMPLOYEES’ PENSION SCHEME, 1995
izi= Hkjus ls igys funsZ”kksa dks i<s+a@(Read the instructions before filing up this form)
;fn lnL;rk 180 fnu ¼xSj va”knk;h lsok dks NksM+ dj½] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA WITHDRAWAL BENEFIT IS NOT ADMISSIBLE IF
MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRIBUTING PERIOD

1.

¼d½ lnL; dk uke ¼Li’V v{kjksa es½a @ Name of the Member (In Block Letters): ____________________________________________
¼[k½ nkosnkj dk uke
Name of the claimant (s): ______________________________________________________________________________

2.

tUefrfFk@Date of Birth (dd/mm/yyyy)

3.

firk dk uke /Father’s Name________________________________________________________________________________
ifr dk uke Husband’s Name (If applicable)___________________________________________________________________

4.

5.

5A)
6.

7.

LFkkiuk dk uke o irk ftlesa lnL; var esa fu;ksftr FkkA@
__________________________________________________________
Name & Address of the
Establishment in which, _______________________________________________________________________________
the member was last employed
dksM la- rFkk [kkrk la{ks=@ dk dksM
LFkkiuk dh dksM la[kkrk laCode No. & Account No.
Region/Off Code
Estt. Code No.
A/c No.

dk;kZjaHk frfFk@Date of Joining the Estt. ___________________________________________________________________
lsok NksM+us dk dkj.k rFkk
lsok NksM+us dh frfFk
____________________________________________________________________________
Reason for leaving service &
Date of Leaving
___________________________________________________________________________
iwjk irk ¼Li’V v{kjksa es½a
Full Address (In Block Letters) ________________________________________________________________________
Jh@Jherh@dqekjh@Sh. /Smt. /Km. _______________________________________________________________________
iq=@iRuh@iq=h@S/o, W/o, D/o._________________________________irk@Adress _______________________________
______________________________________________________________________ fiu/PIN _____________________

# lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fu”kku
Signature or Left / Right hand thumb impression of the member

Form 10C (www.epfindia.gov.in )

# fu;ksDrk ds gLrk{kj /Employer’s Signature

Page 1 of 4

a gkFk ds vWaxwBs dk fu”kku Signature or left Hand Thumb impression of the Member/Claimant # fu. : cSad dk uke ¼Li’V v{kjksa esa@Name of the Bank (In Block Letters) : ________________________________ ________________________________ “kk[kk ¼Li’V v{kjksa es½a @Branch (In Block Letters) : ________________________________ vkbZ-.) under intimation to me..k i= ds fodYi ds fy.k dk ek/.B.. dh e`R.q dh frfFk@Date of death of the member nkosnkjks ds uke@rFkk lnL.8..in ) Page 2 of 4 . D.e ¼fodfYir fof/k ds vuqlkj lacaf/kr dks’Vd esa fVd djsa½ Mode of remittance (put a tick in the box against the one opted) en la... ¼d½ ¼[k½ 11. lnL...q gksus ij] %& In case of death of members after attaining the age of 58 years without filling the claim:lnL.rk 180 fnu ¼xSj va”knk.7 esa fn. ifjokj dk fooj.k vki fudklh ifjYkkHk ds LFkku ij .gov.B. ds lkFk laca/k ukckfyd ds vfoHkkod dk uke Name Date of Birth Relationship with Member Name of the guardian of minor ifjokj ds lnL.@nkosnkj ds gLrk{kj vFkok ck.h lsok dks NksM+ dj½] ls de dh gS rks izR.kr fd. irs ij esjh ykxr ij Mkd euhvkMZj }kjk By postal money order at my cost to the address given against item No.ki= Lohdkj djus ds fy.ksDrk ds gLrk{kj /Employer’s Signature Form 10C (www.kstuk izek...kgj.e ls vknkrk [kkrk lh/ks Hkstk tk..dksM@ IFS Code : ________________________________ “kk[kk dk iwjk irk ¼Li’V v{kjksa es½a /Full address of the Branch (In Block Letters) : _______________________ (vius cSad [kkrs ds [kkyh@jÌ pSd dh .k esja s vf/kdre Kku ds vuqlkj lR.q izkIr djus ds ckn lnL. gka@Yes ugha@No fdlds }kjk tkjh By whom issued………………………………………………………. ls mldk laca/k@Name of the Claminant(s)/and relationship with the member /kuizs’k.. rS. indicate ih-ih-vks..ks..l-. esjs cpr [kkrk la-¼vuqlfw pr cSad@Mkd?kj½ esa js[kfdar psd@ bysDVªkWfud ek/.. Family members ¼d½ (a) ¼[k½ (b) 10... D.@applicable only for Scheme Certificate option) uke tUe frfFk lnL.k ¼ifr@iRuh rFkk cPps rFkk ukfefr½ Particulars of Family (Spouse & Children & Nominee) (flQZ .fn gkWa] rks bafxr djsa If yes. gS@ a Certified that the particulars are true to the best of my knowledge fnukad Date ... Account No..fn lnL.. dh e`R. izekf.k tkrk gS fd fooj. cpr CkSad [kkrk la+@aS.@ (b) By account payees cheque/ electronic mode sent Directly for credit to my S. A/C (Scheduled Bank /P.k vki d-is-a ...epfindia.O. ugh gSaA Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service.7: eq>s lwfpr djrs gq.laPPO No……………….kj gSaA Are you willing to accept Scheme Certificate in lieu of withdrawal benefits . 9.kstuk gkWa Yes ugha No izek.95 ds rgr is”a ku izkIr dj jgsa gSa \ Are you availing pension under EPS-95 \ .k ykHk ns.d izfr layXu djsa Please attach a copy of cancelled/blank Cheque) ______________________________________________________________________________________ 12. ¼d½ ¼[k½ ukfefr Nomine fcuk nkok fn.Q-.. 58 o’kZ dh vk.

........../Cheque................ fooj... lnL............dh vnk... of days fnukad Date ..............ks-½ ml vof/k dk layXu gS ftl vof/k gsrq ... us esjs le{k gLrk{kj fd...kZy.kA Passed for payment for ₹.....“kCnksa esa ----------------------------------------------------------------------------------------------------------------------------..k tk.I......ksxkFkZ (For the use of commissioner’s office) ₹---------------------------------------------------------------------------------------------------.gov. towards withdrawal benefit..... lk-lq-lSSA Form 10C (www.......................................Zos{kd S......A. fu......O. (in words) ...fn ykxw gS½ Wages (Basic +D..k fuEukuqlkj gSa %& The details of wages and period of non-contributory service of the member are as under: ¼izi=&3....---------------------------------------------------------------------------------------------------------. net amount to be paid by M.... ₹ --------------------------------------------------------. gkFk ds vaxwBs dk fu”kku Signature & left hand thumb impression of the member on the stamp izEkkf....qDr@mi&{ks=h......AO........¼”kCnksa es½a --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------½ dh jkf”k izkIr dhA Received a sum of ₹... Hkfo’..O........epfindia.... fjDr LFkku dks {ks=h........ ds gLrk{kj vkSj ck¡........ fuf/k dk.....in ) vuqi.fn dksbZ gS½ ------------------------------------------------------------------------------------------....... dh etnwjh .... }kjk fn........fudklh ifjYkkHk dh fuoy jkf”k ----------------------------------------------------------------------------M....xh en la................ksDrk@izkf/kd`r vf/kdkjh ds gLrk{kj Signature of Employer/Authorised Official vk........................95 (if applicable) lsok R.kr fd...... l-ys-vf/kA... ds iz........) as on 15.... fuf/k vk........ dk........ gSa@vaxwBk fu”kkuh yxkbZ gSA Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me...... FksA½ (Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employees’ Provident Fund Office) fnukad 15-11-95 dks etnwjh ¼ewy osru + egaxkbZ HkÙkk½ ¼.Commission (if any) ...h rjQ fn........... dks Hksts ugha x..S................h lsokof/k ds fooj......k lgh gS vkSj lnL....P............@7½ ¼d-is-a .....xkA The space should be left blank which shall be filled by Regional Provident Fund Commissioner/Officer-in-charge) ₹ 1 jktLo fVdV ₹ 1 Revenue Stamp fVdV ij lnL...) only from Regional Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office.....kZy..s deZpkjh Hkfo’........ Page 3 of 4 .............h lsok dh vof/k % Period of non contributory Service : o’kZ@ekg Year/Month fnu No............qDr dk...½ [To be furnished only in case of (b) above] is”a ku fuf/k [kkrs ds fuiVku Lo:i {ks=h..------------------------............................ (Rupees...... euhvkMZj deh”ku ¼.kZy...ds v/khu@vnk...vfxze izkfIr jlhn Advance Stamped Receipt ¼dsoy Åij ¼[k½ ds ekeys esa gh izLrqr fd.k tkrk gS fd lnL.. Hkfo’....... ds izHkkjh vf/kdkjh ls vius cpr cSad [kkrs esa tek }kjk ₹ ----------------------------------------........... fuf/k vk. M...euhvkMZj@psd Under ₹ ....xh gsrq Lohd`r fd..O ................by deposit in my savings Bank A/c towards the settlement of my Pension Fund Account.............. ck¡...No.qDr@izHkkjh vf/kdkjh }kjk Hkjk tk.....................kxus dh frfFk dks etnwjh Wages as on the date of exit ₹ ₹ xSj v”knk...11................oa xSj va”knk..

) ¼is”a ku vuqHkkx ds iz........ZS......--------------.l layXu gS %& For issue of S.vide Cash Book (Bank) Account No....... vuq i... ftls udn iqfLrdk ¼cSad½ [kkrk la-&10 MSfcV en la............ZS.......¼udnkuqHkkx ds iz.......i. l-Hk-fu-vk.S l........ l-Hk-fu-vk...ksxkFkZ½ (For use in Pension Section) ..kstuk izke........epfindia...AO.......mfYyf[kr gS] dks fnukad -------------------------------------------------------------------------------...ij ntZ dj fy.ki= fu.......gov........10 Debt item No..kstuk izek.a=......vf/k..and entered in the Scheme Certificate Control Register.l.........ZS..........a=......i...tkjh djus ds fy......Mh......k la......C.----------------------------------------------------------------------------------------------------------------------------. Form 10C (www.¼ys[kk½ APFC (A/cs....in ) l-ys-vkA. SSA. l-ys-vkA.S.....l.... Dt .......... IDS is enclosed lk-lq-l- vuq.) Page 4 of 4 .issued on ....k vkSj bldh izfof’V ..¼ys[kk½ APFC (A/cs.------------------------------------------------..... lk-lq-l-SSA vuq.................¼udn½ AC (Cash) ..........S...ki= ftl ij fu.........--------------------------------------------------------------------......k gSA Paid by inclusion in cheque No..dks tkjh fd...... vkbZ.AO....k iath esa dhA Scheme Certificate bearing the control No .fnukad --------------------------------------..}kjk lans.ksxkFkZ½ (For use in Cash Section) psd la..----------------------------------------------------------------------------------------------------------------------------...

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