Professional Documents
Culture Documents
EPS Withdrawal Form
EPS Withdrawal Form
FORM 10 C PENSION
*Mobile No.
_____________________________________________
_____________________________________________
Fathers Name
_____________________________________________
Husbands Name
(if applicable)
_____________________________________________
MH / 18796 /
_____________________________________________
_____________________________________________
_____________________________________________
Teh/District
_____________________________________________
_____________________________________________
Yes
No
Date Of
Birth
Relationship with
Member
Family
Member
(b)
Nomine
e
10. In case of death of member after attaining the age of 58 years without filling the claim:
a) Date of death of member:
b) Name of the claimant and relationship with the member:
11. MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ONE OPTED)
a) By postal money order at my cost to the address given against item no. 7
b) By Account Payee cheque sent direct for credit to my S.B a/c (Scheduled Bank)
Under intimation to me
N/A
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
CERTIFIED THAT THE PARTICULARS MENTIONED ARE TRUE TO THE BEST OF MY KNOWLEDGE
(X)
Date: _________________
(The space should be left blank which shall be filled by Regional Provident Fund Commissioner /
Officer in charge)
Re.1/Revenue
Stamp
(X) Signature or Left hand thumb impression of
the member on the stamp
Certified that the particulars of the members given are correct and the member has signed / thumb
impressed before me.
The details of wages and the period of non-contributory service of the member are as under:(Form 3A/7 (EPS) enclosed for the period for which it was not sent to the employees Provident Fund
Office)
Wages (Basic + D.A.) as on 15.11.95 (if applicable)
Wages as on the date of exit
Period of non contributory service
Year / Month __________________ days ______________
Date: _________________________
Signature of the Employer /
Authorised Official
MH / 18796 /
(FOR THE USE OF COMMISSIONERS OFFICE)
(Under Rs.______________________________________ P.I No.____________________________
M. O. / Cheuqe
Passed for payment for Rs.._________ (in words) ______________________________________
C.C.
S.S.
A.A.O.
S.S.
A.C. (Cash)
C.C.
S.S.
A.A.O.
A.P.F.C(A/cs)
C.C.
Scheme Certificate bearing the control No. _______________ issued on _______ and entered in
the Scheme Certificate Control RegisterS.S.
A.A.O.
A.P.F.C (PENSION)
Mention your Employee Code & Mobile Number on top of the Pension
Withdrawal Form
You are requested to clearly mention all the details in BLOCK LETTERS from
point no.1 to point no.7
Point no.11(b) Compulsory, please mention the complete Saving Bank details
Signature on bottom of the Page 2. Fix revenue stamp & sign across on Page 3
& keep all the details blank