(Pryss Rata fre ora t) (Supplied free of cost) oan te acral, 1995 EMPLOYEES' PENSION SCHEME, 1995 WIA-10 7 (Go Yo Alo) Form 10-C (E.P.S.) Poni oer / aor WATT We A Bg aa WTA Form for claiming withdrawal benefit/scheme certificate fAg=1/INSTURCTIONS er wea ae warm & ? / Who Can apply ? 1. arferd gRare Get aorn, 1971/aferh ders atorn, 1995 71 arg aoe SRT ‘AMember of the Employees’ Family Pension Scheme, 1971/Employees' Pension Scheme, 1995. (@) toad A dar ye wel a ed Prato at vie Rare (2) Who has left the employment before completion of 10 years service, (@) 10d A aan eh ek Ge ae A eed Qe oer da Hare geHhy Soa H rg a YAR gM AL (bo) Whohasattained the age of 58 years before completion of 10 years service -whetherin servicefletthe service (1) Sar sraftt an ort ore 6 mre H aiff B 1 2. Bee, Prey Sar ary BH AA a toad A Sar GA we ch 8 she ga ade TT awa aH AAD ars 58 ae A ong a ora 7é Gar & aT ge orde a aa A aa aw some aA ong TET aR Yor RT oad A gre BR ates Tey 50.4 GH BH A ong a sre aR Gare Te UA we A tes by FEN ae t | ‘A member, who has completed 10 years service on the date of his leaving the service and has not attained the age ‘of 50 years on the date of fling this application or has attained the age of 80 years onthe dateof fling this application or has attained the age of 50 years or more but less than 58 years, and not willing for reduced pension feat ‘feria 1.3,1971 8 frre 15.11.95 TH BH aan (ae wg 2) H 10 a8 H ar eq fen ore Note-1 To determine the period of 10 years service rendered from 1.9.1971 to 18.11.1998 (if any), shall also be taken feemil (i) ve wera, fray 10 af a Bar gh ar ah 2 ote se at A ong a Ber 4 oer Bar A a eT Be ore ae fren & afte weer det bg at Note-lI (i) A member who has completed 10 years service and attained the age of 58 years, whether in service or notis eligible for Monthly Member Pension () weea Pret 10d a ae A aR At ae soad A ong oh Yh a AR dome TAS ord ud a te aa & foe Tae (i) Amember, who has completed 10 years service and also attained the age of 50 years is eligible to draw pension at reduced rate, after leaving the employment ii) ee, RT eH ek were reer eae er ea et eR eA oT she Ben sea Per 9, afte sige te Bg oe | (ii) A member who has let the service on account of total and permanent disablement, irrespective of his age and period of service, is eligible for monthly disablement pension. (wv) afte der & art 2g waa—-10-4 A andes Wega we eee 1 (iv) To claim the Monthly pension, application in Form-10-D should be submitted. 3. Ua oftart wae/Type of benefit eligible : rr Fe tear-1 & oking we wea Pont oRard A af eat et a Tae | ‘A member falling under Item | abbve is eligible to get the amount towards withdrawl benefit. went Grae AE Go — 1 (&) & sini Mide Tees Br weet fan ren & fs ae Pesto mafeensh eq ahora sro & fq soar Roea eA BT | However, a member fang under item 1(a) above is advised to opt for the Scheme Certificate on account of follow ing advantages. () Peet ome eer § torre sre aA oe Gara GS Gar ora wr art fey cE ae SE THT ax tea @ eward @ faPrafia fen oeT | ()Ontaking up employment in another establishment, his eatller service period will be carried forward and clubbing both the spells togehter pension entitlement shall be regulated, (i) a ate ween drome ret AE en ote 50 ad a org wT oa eA a YAM yy oe ah sae afta cota dea ora aeT | (i) Ifthe member does not take up employement and dies before attaining the age of 58 years. His farily will {get family Pension. On his survival, he will get withdrawal benefit with weightage as may be prescribed.(ii) Arsen sero set HRS WHE TERT are fer AA ere a Poh A aig warae Ae 1” (iii) While availing a Scheme Certificate, there is no bar to withdraw the P. F. accumulations by the member." 4. ane Ta AA Bq APfaeA/Guidance for filling the application : “Ghra wm Ho antes A Ah wA To B Haha 8) (S.No. given below refers to the one given in the application) Bao @) WETS Sen aiftdal 8 Re GAN oT ATH ee eR A BRT SLNo-t (a) Write your name in CAPITAL letters as given in the service records of your establishment. (@) Baa Fe ara te Ory oe artes Wee & sfttad fret ora afte Gata aaa ree) ae oR Prat ATT B (b) To be furnished only when the application is preferred by a person other than the memebr himself (i.e. Nominee/tamily member) 2 Fee DH we oH HBS art aey 1 The exact date of birth of the member should be given. 387 ae fare a ate foeh starrer ar aes wt ere wo A ae fea oT aTfeE | fae ge/ser @ amen fea orn ae 1 3t07:- Paniculars should be writen clearly without ary overwriting or cutting. Correction i any, be 8, wee ere fares seh Raft AH far iret & ay se 10-@d aH Aer Ge aE DA & ote Pref Gitar bg oR The option is to be given by the member only if he has not rendered 10 years service and eligible for withdrawal benefit 9. aia cafes ste oa (atest aeh va wh aed) wr Pt fear ew Refs A fear oT ater | Complete particulars of nominee and family (spouse and all children) should be given without fail. 10. 38 aa afer H aren ong wa wah a oa & fee wees are erat weg fare TT a 1 To be furnished when the claim is preferred by nominee or the family member (s).. 11. RF dae wh We far ony oa Tees Pref sari 8g oa et ote Sea ahorn waa B wT wR eH a ‘Reved fear a | Ge TAR ar] Ae 8 GT Aor WATTS eq BoER oerE fore Pont oar & wor we thor seroma #y farsa fen & |) To be completed only when a member is eligible for withdrawal benefit and opted for it in lieu of scheme Certificate (not applicable to those who are entitled for Scheme Certificate or opted for Scheme Cerificate in lieu of with- drawal benefit) 12. af weer afar te thorn, 1995 & atti afta testes @ wer 2 at we flan oH ee) In case, the member is drawing Family Pension/Pension under the Employees’ Pension Scheme 1985, the details should be furnished fit sift wefte/Advance Receipt : ‘ara Wea wr siffTHTOTTA/Attestation of claim form : ern weer: Sa Prataen S arnfers ear enfey forra anita wees oma A Prato a The claim should preferably be attested by the employer under whom the member was last employed. aft fart orves ater artes wt an af Pear 8 otras met 4 oral 3 ch wa aay fH ae Rafa @ Be we A at D Peete aftga santa 4S feet ew 8 aeons eee afte AY arated a anrenfta a 2 | If for any reason, the claimant is unable to get the application attested by his ex-employer, he may forward the claim to the Provident Fund office duly clarifying the position, after getting it attested by any one of the following authorised officials : () sate 3 Ron 8 fret eee wT om aR 8 | (i) Manager of the Bank where the member is holding an account. (i) Serfora een wT MET/Head of Educational institution, (ii) woraPra siffrere/A Gazetted Officer. (v) 9a srmUTE/sTaTTeSub-Post Master. (v) -ARRge/The Magistrate (vi) were ater AA area B daha a aS | (v)_ Memeber of Central Board of Trustees Employees's Provident Fund or Regional Committee (vi) se yae erate / Pret / write as wr aeRT (vil) Chairman/Secretary/Member of the MunicipaVDistrictLocal Board (vil) TH / Weare or ores / wea / ae eA MRT, ATT (vii) President of the village Union / Panchayat / Member of Parliament / Member of Legislative Assembly. (x) Sere fe PRY arr eT orgs we FT safer ()_ Any other officer approved by the Regional P, F. Commissioner 5. aa oa fet anieeizeactoent (ae aig 8) eq Preveors far PAR arated & ores sare (Afeey fA Prderrera A afPafert & ) A eva fare oT wee | 5. For futher guidance/clariications required, it any the Public Relation Officer in the nearest Provident Fund Office (including Provident Fund inspectorates) may be contactedSoe orators & serra wa. For Ofice Use Only Serial No. FAB Ga Ho 10-1 (Gorozo) In ward No. Form No. 10-C (E.P.S.) dant tea aor, 1995 EMPLOYEES PENSION SCHEME, 1995 @fant te ae, 1995 & werd ent daa Pont wRaM/ aa WAPTTA ara eg aT fear GT ae WTA FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME. 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE (waa aA G Teal tet wu) (Read the instructions before filling up this form) 1. (@) wees a ATH (wre see! A) Name of the Member (jetcic atresia a DE AR RE SPE OP JS (@) eer oar Name ofthe claimants) 2. aafeafe Date of Birth 3, fen @T ATVFather's Name = uid @T AT Husband's Name (If applicable) ee ees a i 4. RAT &T ATH a aT fo weet sa A Praifera a — Name & Address of the Establishment in which, the member was last employed 5. as a. on aM a. A/so Bo Ho BS Code No. & Account No. Region/SRO Code wa BH BS Go arm a. Est. Code No. Are No. SA Date of Joining the Estt. 6. 8a BISA H ORT aa Bar Biss at fA Reason for leaving service & Date of leaving SS a a 7. FR eH (eae tera a) Full Address (In Block Letters) hate, /apATaY/ShJSmtke, A/F TAL/ Slo, Wio, Dio8 Fama Pert oar } wr ww arorT ) @ sara eto wet & feng day et a @) ©) Are you willing to accept Scheme Certificate a ae in ou of withdrawal benefits Yes No 9, afta at fae (@RA/aeH ae aed ae aT) Particulars of Family (Spouse & Children & Nominee) a orate wee } we ae arate & sfteraa a are Name _Dateof Birth Relationship with Member Name of the guardian of minor (@) char & wee (@) Family members (@) aiteta ©)_Nominee 10 58 8 @ og ard at S ae wee A gy OR PT aa Ry Incase of death of member after attaining the age of 58 years without filing the claim :- (@) ween A ey AA Date of death of the member (a) aden & aeyan wee 8 saa wie ‘Name of the Claminant(s)/and relationship with the member 11, ete or ara Rewfeaa AA d sR vada sew 4 Ro wy) Mode of remittance (put a tick in the box against the one opted) (@) eH. 7 9 Re aa we AD ora we srw AME ET By postal money order at my cost to the address given against item No. 7 (@) wen 8A Ae shen AY de (TaPea Fw/srweR) A aaa UTA A eM aq aa 2) ah wT aa A al ‘Account payees cheque sent direct for credit to my SB A/c (Scheduled Bank) Under intimation to me. aad te ait tio /S.B. Account No. ap or am (ere send A) Name of the Bank (In block letters) ‘Wal (BRE BRI AyBranch (In block letters) : ‘Ural tw sen GA eRe 8) Full address of the Branch (in block letters) 12, FA 9 Go Ho Mo.95 S aed Ver wre GX Ww 2? ‘Are you availing pension under EPS-95? aft a, a gfita at lo fo ai. tio fared ari aire Ito, indicate PPO No. By whom issued, arate frat rat & fe ar AR aeae a S sigue wee) Cerlfied thatthe particulars are true to the best of my knowledge. reer eRe Geren aT aie sigs Pree feos Signature or left Handi Thum Date imprecsion ofthe Member claimant (s)orfirs oft wee ‘Advance Stamped Receipt [daa SR (@) $a | A RGA Pra IG [To be furnished only in case of (b) above] Oem AR aid $ Ayer eres date wae A organ /er aaa orate & wan aE Ba Ta Fa . a 3 om ETE vo (ara 8) Ss) a ao ores a) Received a sum of Rs. (Rupees. : eee a eee .) only from Regional Provident Fund Commissioner/Ofticer-in-charge of Sub-Regional Office by deposit in my savings Bank Alc towards the settlement of my Pension Fund Accourt. ahh are fey Rad wera wy eta wfaey FA orqad/m slerd gra wR aT The space should be left blank which shallbe filed by Regional Provident Fund Commissioner/Otficer-in-charge) Roe we weer } eemen ote dla aa & aid a Pre Feo + eared ‘Signature & left hand thumb impression of the member on the stamp. fewe Sane sears Roan omen & A eee arer Fy Rae wl 8 ote aoe a AY wae wee Py B/oiqST Pre arg & Certified thatthe particulars of the member given are correct and the member has signed/thumb impressed belore me. wee oY HIgh a AK sinerh dara } Rae Range &— ‘The details of wages and period of non-contributory service of the member are as under : (a4.39/7) (@otioro) a taRY ar dior & fore ora bq & alarh wider FHA arafora ay AY aE ay a) (Form 34/7 (EPS)] enclosed for the period for which it was not sent to Employees’ Provident Fund Office) Review 15.11.95 B MAGA (Ge Ae + emg a) (AA ary 2) Wages (BasicsD.A) as on 15.11.95 (t applicable) aan carey aH PARI ay IGA Wages as on the date of exit ay sere Gar A sah Period of non contributory Service aise fea Year’Month No.of days Rete Prabang stad & Keene Date. ‘Signature of Employer/Authorised Official argent wrafera @ wethref (For the use of commissioner's office) ¥o conan SEE/ SETI FE BO cone on ATER BH (Under Rs. sssseece PA. NO. ... M.O0./Cheque. ¥o sat 4 A serath 8g eiiga fT Passed for payment foF RS... Words) : — wearde waar (af @g 2) cone PRERA URATH A Pree TRI M. ©. Commission (if any) net amount to be paid by M. O. towards withdrawal benefit tio fio sequelae odosifto DH. SS. AAO.(Awergara & satel) (For use in Cash Section) ‘Be Ho - cenrnnnnnnes RAAB a oR HAY FORE aTeHS gGfterer a) wre ‘Ho-10 Sfte AZ Ho nl smmcnnmconen OR BE BR fora BI Paid by inclusion in cheque No... se DL sasissstssstanaees Vide Cash Book (Bank) Account No. 10 Debit item NO, sn aq who Wo ato (752) 8.8. ‘AC (Cash) WW, og. BUH. 8g TTA aed SB fy das BH For issue of S, S. ; IDS is enclosed Ho fo argo who Ho Fomo ovioPtosio (eal) DH. SS. AAO. APFC (A’cs.) (Gar gary & wartef) (For use in Pension Section) TSA WATT PERT TR FAA Bo oe . Sfeahaa 8, a PEATE nmin OY GIR fret she ga WARE ctor waa Precaer doh A ay Scheme Certificate bearing the control NO, ....rs..nennsennne $8UOD OM os .and entered in the Scheme Certificate Control Register. Ho fio so wo wo aosifte woroPoane (Fe) DH, s.S. AAO. APFC (Pension)