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Form10C PDF
Form10C PDF
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 isa ku ;kstuk] 1995 EMPLOYEES PENSION SCHEME, 1995
izi= Hkjus ls igys funsZkksa dks i<s+a@(Read the instructions before filing up this form)
;fn lnL;rk 180 fnu xSj vaknk;h lsok dks NksM+ dj] 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.
2.
3.
5.
5A)
6.
7.
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8.
9.
d
(a)
[k
(b)
10.
d
[k
11.
d
[k
ukfefr
KANCHAN
02-04-1964
MOTHER
Nomine
fcuk nkok fn, 58 okZ dh vk;q izkIr djus ds ckn lnL; dh e`R;q gksus ij] %&
In case of death of members after attaining the age of 58 years without filling the claim:lnL; dh e`R;q dh frfFk@Date of death of the member
nkosnkjks ds uke@rFkk lnL; ls mldk laca/k@Name of the Claminant(s)/and relationship with the member
/kuizsk.k dk ek/;e fodfYir fof/k ds vuqlkj lacaf/kr dksVd esa fVd djsa
Mode of remittance (put a tick in the box against the one opted)
en la- 7 esa fn, irs ij esjh ykxr ij Mkd euhvkMZj }kjk
By postal money order at my cost to the address given against item No.7:
eq>s lwfpr djrs gq, esjs cpr [kkrk la-vuqlfw pr cSad@Mkd?kj esa js[kfdar psd@ bysDVkWfud ek/;e ls vknkrk [kkrk lh/ks Hkstk tk,@ (b) By account
payees cheque/ electronic mode sent Directly for credit to my S.B. A/C (Scheduled Bank /P.O.) under intimation to me.
cpr CkSad [kkrk la+@aS.B. Account No.
cSad dk uke LiV v{kjksa esa@Name of the Bank (In Block Letters) :
________________________________
________________________________
ALLAHABAD BANK
BANGLA BAZAR
kk[kk LiV v{kjksa esa @Branch (In Block Letters)
:
________________________________
ALLA0212325
vkbZ-,Q-,l-- dksM@ IFS Code
: ________________________________
kk[kk dk iwjk irk LiV v{kjksa esa /Full address of the Branch (In Block Letters) :
_______________________
584 Ka/314 Jail Road, Bangla Bazar, Thakur Dwara
Mandi, Cheque)
Luckow.
(vius cSad [kkrs ds [kkyh@j pSd dh ,d izfr layXu djsa Please attach a copy of cancelled/blank
______________________________________________________________________________________
12.
gka@Yes
ugha@No
izekf.kr fd;k tkrk gS fd fooj.k esja s vf/kdre Kku ds vuqlkj lR; gS@
a Certified that the particulars are true to the best of my knowledge
fnukad
Date .......................
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izEkkf.kr fd;k tkrk gS fd lnL; }kjk fn, fooj.k lgh gS vkSj lnL; us esjs le{k gLrk{kj fd, gSa@vaxwBk fukkuh yxkbZ gSA
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.
lnL; dh etnwjh ,oa xSj vaknk;h lsokof/k ds fooj.k fuEukuqlkj gSa %&
The details of wages and period of non-contributory service of the member are as under:
izi=&3,@7 d-is-a ;ks- ml vof/k dk layXu gS ftl vof/k gsrq ;s deZpkjh Hkfo; fuf/k dk;kZy; dks Hksts ugha x, FksA
(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 ewy osru + egaxkbZ Hkkk ;fn ykxw gS
Wages (Basic +D.A.) as on 15.11.95 (if applicable)
lsok R;kxus dh frfFk dks etnwjh
Wages as on the date of exit
fnu
No. of days
fnukad
Date ..........................
lk-lq-lSSA
vuqi;Zos{kd
S.S.
l-ys-vf/kA.AO.
Page 3 of 4
udnkuqHkkx ds iz;ksxkFkZ
(For use in Cash Section)
psd la- ----------------------------------------------------------------------------------------------------------------------------- --------------- fnukad --------------------------------------- }kjk lans; ftls udn iqfLrdk cSad [kkrk
la-&10 MSfcV en la- --------------------------------------------------------------------- ij ntZ dj fy;k gSA
Paid by inclusion in cheque No.............................. Dt ............................vide Cash Book (Bank) Account No.10 Debt
item No...............................................................
vuq i;ZS.S
l- vf/k- udn
AC (Cash)
lk-lq-l-
vuq- i;ZS.S.
SSA.
l-ys-vkA.AO.
l-Hk-fu-vk- ys[kk
APFC (A/cs.)
lk-lq-l-SSA
vuq- i;ZS.S.
l-ys-vkA.AO.
l-Hk-fu-vk- ys[kk
APFC (A/cs.)
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