FORM No.

10 - C

(E.P.S.)
Inward No:

EMPLOYEE'S PENSION SCHEME - 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Read the instruction before filling of this form) 1 (a) Name (b) Name 2 Date

of the member (in Block Letters) of the claimant(s)

of Birth Name Name (if applicable)

3 (a) Father's

(b) Husband's

4 Name and address of the Establishment in which, the member was last employed

5 Code

No. & Account No.

RO/SRO Code Estt Code No.

A/c No.

6 Reasons

for leaving Services

Resigned

& Date of Leaving
7 Full Postal Address (in Block Letters) Sri / Smt. / Kum. S/o. / D/o. / H/o. / W/o.

PIN : 8 Are you willing to accept Scheme Certificate in lieu of Withdrawal Benefits ? (a) Yes (b) No

9 Particulars of Family(Spouse,children or Nominee Name (a) Family member/(s)

Date of Birth

Relationship Name of the with the member guardian of minor

(b) Nominee

10 Incase of death of the member after the age of 58 years without filing the claim :

(a) Date of death of the member (b) Name of the claimant(s) and relationship 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 to the 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 No ECS Code No. Name of the bank(in block letters) Branch(in block letters) Full postal address of the Branch (in block letters)

PIN 12 Are you availing pension under EPS-1995 if so,indicate PPO No

by whom issued

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date

Signature/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/c towards the settlement of my Pension Fund account.

The space should be left blank which shall be filled by this office.

Affix Rs 1 Revenue stamp

Signature/left hand thumb impression of the member on the

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me. The details of wages and period of non-contributory service of the member are furnished under (Form 3A/7(EPS) enclosed for the period for which was not sent to Employees' Provident Fund Office).

Date of joining Wages (Basic+D.A) as on 15/11/95 (if applicable) Wages on the date of exit Y Period of non-contributory service M D

Date

Signature of Employer/Authorised Offical with Rubber stamp

(FOR THE USE IN OF COMMISSIONER'S OFFICE (Under Rs ____________________________ P.I. No_____________________ M.O/cheque __________________ passed for payment for Rs_____________ (Rupees_____________________________________________ only) M.O Commission(if any)Rs______________ net amount to be paid by M.O _______________ towards withdrawl benefit

D.A

S.S (FOR USE IN CASH SECTION)

A.AO

Paid by inclusion in cheque no_______________________________date _______________vide Cash Book Account no.10 Debit Item No. __________________

D.A For Issue of S.S. ; IDS is enclosed.

S .S

AC(Cash)

D.A

S.S ( FOR USE IN PENSION SECTION)

APFC(A/cs)

Scheme Certificate bearing the control no Scheme Certificate Control Register.

issued on issued

and entered in the

D.A

S.S

APFC(Pension)

Sign up to vote on this title
UsefulNot useful