(~ ~ ~ \jff() ~)

(Supplied free of cost)

,

41U1 .... 1, 1995 EMPLOYEES' PENSION SCHEME, 1995 ~-1 0 "IT (cpo tio mo)

Form 10-C (E.P.S.)

~ChI:A'l qR61llT/-1I\JFll w11olQ?l m"CG ~ ~ 3i1~G"i ~ Form for claiming withdrawal benefit/scheme certificate

~"/INSTURCTIONS ~~ CIR ~ t ? / Who Can apply ?

1. ¢~=ql'<~ ~ m~. 1971/¢~=q1;fl m~. 1995q)l ~ ~ ~

A Member of the Employees' Family Pension Scheme, 1971 IEmployees' Pension Scheme, 1995.

(Cli) 1 0 ~ ~ mn ~ m ~ wf ~41\i1~ em ut? ~ ~.

(a) Who has left the employment before completion of 10 years service.

(~) 1 0 ~ qft ~ ~ m ~ wf ~ 1) m ~ 3iemr ~ cf; iITG 3i~ 58 ~ qft ~ em ~ QR ¥1 51 I (b) Who has attained the age of 58 years before completion of 10 years service - whether in servicelleft the service

('1) ~ ~ q)l ~ q;rc;f 6lIT6 cf; ~ 51 I

2. l0l?~. ~ ~ cmrA qft ~ em 10 ~ qft mrr ~ ~ c* ~ 3fR ~ ~ em ~ qft ~ (fCJi 58 ~ qft ~ em mlO ~ S3lT ~ m ~ ~ em ~ qft ~ ClCfi 50 ~ qft ~ mlO CfR Wf>T t m 50 ~ qft ~ ~ 3lft)q; ~ 58 ~ qft CJj"q qft ~ em W!(f CfR ~ ~ ('I'm ittt ~ qft m ~ ~ ;ffll t I

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 filing this application or has attained the age of 50 years on the date of filing this application or has attained the age of 50 years or more but less than 58 years, and not willing for reduced pension.

fVqur-1 : ~ 1.3.1971 ~ ~ 15.11.95(fCJi qft ~ (~~ ~) em 10Cflt qft ~ ~ ~ ~ I

Note-I: To determine the period of 10 years service rendered from 1.3.1971 to 15.11.1995 (if any), shall also be taken.

~-II (i) ~~. RiRR 10 ~ qft mn ~ CfR c* ~ 3fR 58 ~ cGr ~ em mn 1% ~ ~ 1)"'f m

~ "Slll(f CfR ~ t fiq; ~ m ~ tmJ ~ I

Note-II (i) A member who has completed 10 years service and attained the age of 58 years, whether in service or not is eligible for Monthly Member Pension.

(ii) ~ ~ 10~ qft ~ ~ CfR c* ~ ~ 50~ cGr ~ ~ ~ QR C*~. ~ ~ cf; ~ittt~tRm~cf;~tmJ~ I

(ii) A member, 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.

(iii)~. ~ ~ ~ ~ 3WTffi ct; Cf>RUT mn ~ cfr ~ ~ ~ ~ 3fR ~ ~ ~ ~51.fiq;~m~tmJ~ I

(iii) A member who has left the service on account of total and permanent disablement, irrespective of his aqe and period of service, is eligible for monthly disablement pension.

(iv) ~ m cf; ~ ~ >rQ?r-10-~ 1) ~ }ffijO ~ ~ I

(iv) To claim the Monthly pension, application in Form-10-D should be submitted.

3. 'Q1?1 ~ ~ J,cr;T~/Type of benefit eligible:

~ l!G ~-1 cf; 3ffiTrn ~ ~ ~ ~ qft ~ em "Slll(f m q)l qr;r ~ I A member falling under Item I above is eligible to get the amount towards withdrawl benefit.

(f~ \PR 11G ~o - 1 (q;) cf> ~ ~ ~ em ~ ~ \ffiffi ~ fcl; ern ~h1~R!J(1 ~3fi ~ m-wn

~P11 ulQ ~ cf; ~ 3itFff fcIcPc;q mw=r cR I

However, a member falling under item 1 (a) above is advised to opt for the Scheme Certificate on account of follow-

ing advantages. . .

(i) ~ 3Rl ~ 1) ~ "Slll(f m tR ~ 1cf mn ~ em 3nTr 1l'A1 ~ Cfm ~ ~

CfR m qft ~ em ~~1I~(1 fcl;m ~ I

(i) (ij)

On taking up employment in another establishment. his earlier service period will be carried forward and clubbing both the spells togehter pension entitlement shall be regulated.

~ ~ ~ ~ W!(f ;ffll qmn t 3fR 58 ~ qft ~ em "Slll(f ~ ~ wf ~ ~ m ~ t

m \ffiCPT ~ .~ m" "Slll(f CfRcn I

If the member does not take up employement and dies before attaining the age of 58 years. His family will get family Pension. On his survival, he will get withdrawal benefit with weightage as may be prescribed.

(ii)

•

•

(iii) ~ ~PiloI4?1 mta ~ ~ ~ GRT ~ ~ ~ cGt P!CfjI'ffl 1l ~ ~ ~ ~ I'

(iii) White availing a Scheme Certificate, there is no barto withdraw the P. F. accumulations by the member." 4. ~ tBr ~ ~ "'I'fc:'f~/Guidance for filling the application:

'(~ Wlf ~o ~ 1l eft ~ ~o ~ ~ ~)

(S.No. given below refers to the one given in the application)

~ tio-1 (-q;) ~ r$ ~ ~ 1l ~ 3lJfIN 31CFIT ~ ~ 3laffl 1l ~ I

SI. No.-1 (a) Write your name in CAPITAL letters as given in the service records of your establishment.

({g) ~ \3"ti ~ ~ ~ \i'fET ~ ~ r$ ~ ~ ~ ~ (~ ~/~

~) GRT ~ fcmrr \ilRT ~ I

(b) To be furnished only when the application is preferred by a person other than the memebr himself (Le. Nominee/family member)

~ cGt ti1fr \1Fff ~ eft ~ ~ I

2.

The exact date of birth of the member should be given.

3 ~ 7 (fCfj ~ em w M 3I1Clxxillteil m ~ em ~ ~ ~ 'll6i ~ \ifRT ~ I M ~ WG/WA q» 3lfi1wnfUm fcmrr \ilRT ~ I

3 to 7 : - Particulars should be written clearly without any overwriting or cutting. Correction if any, be attested.

8. ~ GRT fctq;(;q \ffi't ~ 1l ~ \ilRT ~ ~ ~ 10 em cGt ~ ~ ~ cGt 'g 3fR PtCfjlft"l ~ ~ l:lT3f ~ I The option is to be given by the member only if he has not rendered 10 years service and eligible for withdrawal benefit.

9. 'iTflm ~ atR ~ (~m~ -qq wft~) em ~ fcIcRur 6'<' ~ 1l ~ \ilRT ~ I Complete particulars of nominee and family (spouse and all children) should be given without fail.

10. ~ mr ~. -q c;rrm ~ ~ ~ m ~ r$ M ~ GRT GfCf[ m:wr fctrm 11m 51 I To be furnished when the claim is preferred by nominee or the family member (s).

11: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 51 atR \NA ~ wilol4?1 r$ ~ tR ~ ~ ~ ~ 51 I ("l16 \R tR <WJ_-;:ffl'l ~ 'Gfr ~ w11014?1 ~ ~ ~ ~ ~ ~ ~ ci> ~~ tR ~ ~P1lolq?l ~ fctcf>c;q ~ ~ I)

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 Certificate in lieu of withdrawal benefit.)

12. ~ ~ Cfj4i11~ ~ mwn. 1995 if; ~ ~ m/m ~ xm ~ en \ffi fcrcRuT ~ ~ I

In case, the member is drawing Family Pension/Pension under the Employees' Pension Scheme 1995, the details should be furnished.

3lflti1' ~ ~/ Advance Receipt:

GTClT ltlJ?I q;J ~/ Attestation of claim form:

zyn ~: \3"ti Pt~~CfdI ~ 3lfi1wnfUm ~ ~ fGmct; ~ ~ 3Rf 1l P!~,It1C1 ~

The claim should preferably be attested by the employer under whom the member was last employed.

~ fcmfr CfllxOlq~1 GfcrGR ~ em 3ltR ~ P!~~CfdI ~ ~ ~ 1l ~ ~ en \ffi ~ f$ CT6 ft~ em ~ Cf>ffl sq Gfcl' em Pt9~ltlff ~ ~ 1l ~ ~ ~ ~ ~ ~ ~ ~ Cfl141<"14 em 3'l!H'1IRC1 q;x ~ I

. 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 anyone of the following authorised officials:

(i) \3"ti ~ cf; ~ ~ ~ ~ em ~ ~ ~ I

(i) Manager of the Bank where the member is holding an account.

(Ii) ~Ifffitrq; ~ em mwf/Head of Educational institution.

(iii) xl\i1Q8ld ~/A Gazetted Officer.

(Iv) \)q 'SICflQI<"1/'SICfl41<"1Sub-Post Master.

(v) &l1t1~c/The Magistrate

(vi) ~~~~r$~~~ I (vi) Memeber of Central Board of Trustees

Employees's Provident Fund or Regional Committee

(vii) 3fC2l~/~/"1'lx41~CflI/~ / ~ ~ em ~

(vii) Chairman/Secretary/Member of the Municipal/DistricVLocal Board

(Viii) ml1/~ em 3fC2lal/~/~ ~/~ ~

(viii) President of the village Union / Panchayat / Member of Parliament / Member of Legislative Assembly.

(ix) aEfm ~ ~ 3WJCfd' GRT 31jS1'I~C1 ~ ~ ~

(ix) Any other officer approved by the Regional P. F. Commissioner

5. ~ ~ ~ !Ofl'h~~~"1/fqce'lCflxol ~ ~ ~) ~ PtCflcC1!Of ~ ~ CfjI4~C'14 cf; \JHfi4rfi ~ (~

~ ~~ ~ f1!4i~C1 ~ ) ~ ~ ~ '\JfT ~ ~ I

5. For furher guidance/clarifications required, if any the Public Relation Officer in the nearest Provident Fund Office (including Provident Fund Inspectorates) may be contacted.

•

~ q> I £If &1 £I cf> w:n.n0 For Office Use Only

Wll fr.

Serial No .

31Tqq) fro .

In ward No .

~ "flo 10-71 (Ci>o-Q-omo) Form No. 10-C (E.P.S.)

Cf) 4'i11 ;fl -Q"fA' 4t \it "11 , 1995 EMPLOYEES PENSION SCHEME, 1995 ij)4illx~ ~ 111 Vi "1 I, 1995 cf> ~ &m cf>cR;r Plij)I-Bl llftc'lT+{ / III Vi "1 I ~ Ii I 0 I q ~ cf> ~ ~ >PiTT[ fcpm "GfT;) CITc11 ~

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE

(~ ~ i1 ~ ~vr'i c5r qc$)

(Read the instructions before filling up this form)

1. (Ci» ~ Cf)l ~ (~ 3leRT if)

Name of the Member

(In Block Letters) : . _

(~) C;I~C;I'< Cf)l ~

Nameoftheclaimant (s) : _

2. Vi;:yFc1 ~ Date of Birth

3. tttdT Cf)f -;wvFather's Name-,-- _

qfffCf)l~

Husband's Name (If applicable) _

4. x~ Cf)l ~ q q(fl ~

~ 3Rt if Pm1 ft1 C1 ~ I

Name & Address of the

Establishment in which,

the member was last employed

5. cirn"fl. ~~ mm fT.

Code No. & Account No.

ef::f/Bo eto Cf)T~ .~ R~~ionlSRO Code

~ qft.~"flo Estt. Code No.

mm ff. Alc No.

5A Date of Joining the Estt. _

6. xlcrr ~ Cf)l cpffOf ~~ xlcrr ~ qft ~

Reason for leaving service & Date of leaving

7. tpT q(fl (~ 3leM If)

Full Address (In Block Letters)

~/~/~/Sh.ISmt.lKm ..

~--------------------

~/~/git/S/o, Wlo, 0/0

_________ fi:t;:f/PIN, _

8. CFn 3Wl ~Cf)If1~ ~ cfi ~ lR ~ (q)") (~)
!>l~lolq=::l ~ ~ cfi ~ chn-x ~ I (a) (b)
Are you willing to accept Scheme Certificate '" ~
6l D D
in lieu of withdrawal benefits Yes No 9. ~"Cf)l fcrcRuT (qfc'f/lW'fi c=r~ ~ c=r~ ~) Particulars of Family (Spouse & Children & Nominee)

~ . \i141 fd ~ ~ cfi "fIl~ ~'tl

Name

Date of Birth Relationship w~h Member

~liSllf~1l1 cfi ~ "Cf)l ~ Name of the guardian of minor

(q)") ~ cfi ~ (a) Family members

(~)~ (b) Nominee

10. 58 ~ ~ 3lTg ~ m cfi "iSITG ~ ~ ¥J m lR. frt;n GJCrr ~ ;-

In case of death of member after attaining the age of 58 yearswithout filing the claim ;-

(q)") ~ ~ ¥J ~ ~

Date of death of the member

(~) GI~GI'<~ cfi ~/c=r~ ~ ~ ~ ~'tl

Name of the Claminant(s)/and relationship with the member

11. ~ "Cf)l lfTUl1l (fcl Cf) fc;qd fclft) cfi ~ ~ ~ 1) ~ cR) Mode of remittance (put a tick in the box against the one opted)

(q)") l1G~. 7 1) ~ qtl lR ~ CWTC'f lR ~ ~3ITtx &NT

By postal money order at my cost to the address given against item NO.7

~) "ffiffi chfr ~ m ~ ~q)" (31j~d ~q)"/;gICf)EH) 1) ~ m() 1) \JflfT m ~1)\Jf~I~~~1frml

Account payees cheque sent direct for credit to my SB Alc (Scheduled Bank) Under intimation to me.

D

D

~ ~q)""ffiffi ~o IS. B. Account No. ~q)" "Cf)l "fl11 (~ 3laRr 1))

Name of the Bank {In block letters)

~ ~ 3laffl l)-YBranch (In block letters)

Full address of the Branch (in block letters)

12. Cfm 3Wl q)"o qo mo-95 cfi C'f6C'f q~ ~ qJX ~ ~?

Are you availing pension under EPS-95?

~ 61. m tf1'm cR

If so, indicate

~o ~o 311. ~o

PPO No .

fcRrcf> &NT ~

By whom issued .

I'l ~ I fOld ~ \JlTffi ~ fct fctcRur ~~ ~11 ~ cfi 3lj~ ~ ~ I Certified that the particulars are true to the best of my knowledge.

~..nq; :

Date .

~ cfi ~m 3l2lCfl ~

6l~ "Cf)l 3l1J:Ol ~

Signature or left Hanel Thumb impression of the Member / claimant (s)

~ ~ ~ * ~e:R 3ftx ifm 6l~ * ~ CJil f.'mA Signature & left hand thumb impression of the member on the stamp

3ifitq ~ ~

Advance Stamped Receipt

~ WR (~) * ~ II ~ ~Cl f$<n ~

[To be furnished only in case of (b) above]

1)~ ~ ~ * f.1Qcl'1 ~ al~ ~ ~ ~/\J1l-ahfm Cflllll(qll * 1)~ ~ ~ 3JtA ifflCl ~cp

~ II \Jfln &TXT XlO (~ ll) ) cGr

~~~I

Received a sum of Rs (Rupees ) only from Regional

Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office by deposit in my savings

Bank Nc towards the settlement of my Pension Fund Account.

~ ~ ~ fuffi" ~ Cfi1 ahfm ~ ~ ~/~ ~ &TXT lRT ~ 1

The space should be left blank which shall be filled by Regional Provident Fund Commissioner/Officer-in-charge)

Rs. 1 Revenue StarT1>

l'I~lfUld f$<n \JITdl ~ f¢ ~ &TXT ~ ~ ~ ~ 3ftx ~ ;) ~ ~ai ~e:R ~ ~/~ ~ ~~I

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.

~ ~ ~ ~ TR ~ ~ * ~ f.191'j'<11'< ~ ;-

The details of wages and period of non-contributory service of the member are as under:

~-3~/7) (cPoqo<ho) \ffi ~ CJil ~ ~ ~ ~ ~ ~ Cfl4~1~ ~ f.1fit =Cflrrilll~'=(qrTTll em ~ ~ ~ ~ I) (Form 3N7 (EPS)] enclosed for the period for which it was not sent to Employees' Provident Fund Office)

f0TIcp 15.11.95 em ~ (~ m + ~ 1ffIl) (~ ~ ~) Wages (Basic+DA) as on 15.11.95 (it applicable)

Wn ~ cGr ~ Cfi1 ~

Wages as on the date of exit

TR~WncGr~

Period of non contributory Service

crf/~ ~

Year/Month No. of days

~ f.1~~CffiI/~ ~ * ~e:R

Date.......................... Signature of Employer/Authorised Official

~ (6I~f('1~ 16 ~<i1.I1~ (For the use of commissioner's office)

XlO * ~/~ lfG ~o ~~;trcP

(Under Rs P.I. No M.O.lCheque.

XlO ~ ll cGr ~ ~ ~ ~ 1

Passed for payment for Rs (in words) .

~~ CflJi~~I'1 (~ ~ ~) f.1Cfllfl"l ~ cGr f.1cr<;r '<1ftr .

M. O. Commission (if any) net amount to be paid by M. O .

towards withdrawal benefit.

~o fc;jo D.H.

~a1cP S. S.

~o~o3lfQo . A. AO.

Xlo ~o D.H.

3lJo ~o S.S.

Xl 0 "R 0311 0 A.AO.

Xlo1fo~03l10 ~) APFC (Alcs.)

(~ ~ W4'411~) (For use in Cash Section)

~ ~o ~ :6m m ~ ~ ~R:t1Cf)1 ~q;) ~

~0-10~ 1fG ~o tR G'Gf q;x ~ tl

Paid by inclusion in cheque No. . Dt. vide cash Book (Bank) Account

No. 10 Debit item No ..

3IJ ~o S. S.

Xlo 3rlao ~) AC (Cash)

~. ~. ~. ~. ~. ~ \ifRl m * ~ ~ ~ ;For issue of S. S. ; IDS is enclosed

/ ----------~---------------------------------------------------------

(~ 3Tj11T'T ~ Si4'4I1d) (For use in Pension Section)

~ SOl 1'1 01 q '::4 ~ tR ~~'::4ol ~o \3r@~(1 t. cp)

~ cp) ~ ~ 3tR ~ ~ ~ SOl '1 1 01 q '::4 ~~'::4OI ~ -q ~ I

i Scheme Certificate bearing the control No issued on and entered in

the Scheme Certificate Control Register.

Xlo ~o D.H.

3IJ0 ~o S.S.

Xlo "Ro3rlao A.AO.

Xlo1fo~03l10 (q~) APFC (Pension)