~

W'/ Mobile Number

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For Office Use Only

I.D .......................

(iI;:lf:~.)

~104l

APPLICATION

fcml' et;

1.

&m WrI

IN'JI

<PT ~

cm ~

if 1I1f

FOR MONTHLY PENSION FORM-IO-D (E.P.S.)

~mt~.11l96
(EMPLOYEES' PENSION SCHEME, 1995)
~
~/(Read
INSTRUCTIONS before filling In this Form)

mn t ?

2.

By whom the Pension is claimed?

3.

(C/i) ~

GT<Il ~ 'l{ ~ <PT W/iR

Type of Pension Claimed

'lI1l'Rf 1l) Member's Name(1n Block Letters)

</iT "'fl1f ~

(<if) 1Wr/ SEX:

T) ~
(q)

~/Marital

\jfi'<J

Status

~/3mj/Date

of Birth/Age (dd/rnmlyyyy)
1

11

11

@") furr/'lFct </iT "lJ1'I/Father's/Husband's Name

4.

C/i. "If. f.I. Wffi

"ffi:lm/ E.P.F. Account Number

>PT

OFFICE

5.

</iT 'Wl" q 'IT

v ~

&'<f -l( ~

mo.rRm "'I.
Establishment Code No.

<PT ffiCIT

"ff.

Member's Ac.No.

t.lT

Name & Address of the Establishment

in which the member was last employed

6.

mrr ~

7.

mrr ~

</iT <IiR"T /

8.

'l?! ~

(a)

~/~

~ ~

/ Date ofleaving Service (dd/mmlyyyy) :

'lOT /

Reason of leaving Service

11

11

~--~~==~==~~I

Address for communication

In case ofreduced pension (opted date

for commencement of pension.)

~ "iffi'llffi/Signature of member la pplicant

Form lOD (www.epfindia.gov.in)

~/Date

lffl\"/Month

qrf,lYear

et; "iffi'llffi/Signature of Employee's

Page 10f6

et; ~

1f;<! 'IINifflCj)~ol

indicate the quantum)

# 'i'l\'\ <t'l ~

10.

fi't<I;(;q

[(./)

WTflf]

CJ

fi't<I;(;q <t'l tffiG q;'r <:Wl1

If yes, indicate your choice of alternative

'i'l\'\ <t'l

11. #

3ItR

CJ

[!][2Jw

cm I

"fIfim mfctff "CI>T

~ ~

"Cf"Ttffit ~

"'lift /No

~ /Yes

Option for Return of Capital. Put a tick (./)

"!1ft ~ <IT

If Yes, Quantum

,-------,I D

'1<lT <IT

-mt"CI>T~~
(If option is for lesser
Commutation

"'lift INo

~ IY es

-mt et; 1/3 'lflT et; tfl~IJlqCj)~OI i!jf fi't<I;(;q

Option for commutation of 1/3 of Pension

9.

Mention your Nominee for Return of Capital

~/
Name

ml

Relation

w<I ~/Date

I I I I I I I I

of Birth) (dd/mmlyyyy)

'lOl/ Address

#~
12.

26.09.2008 lIT ~
<PT f<tcRuT/

""

tm;r ~

Wr.1t fit; ~

"if ~

~/Not

applicable if pension start date is on or after 26-09-2008.

Particulars of Family

~. <to

\iI""1~/~

SI.No.

Name

Date of
Birth/Age

Relationship with Member

:~

iltt.rr

tf

et; ~

<:Wl/lndicate

Guardian Name

fc/q;ffi7r ~ <IT "fT1{ et; ~

'arn<ffi'

against Minor

~et;"Wl"m

~<PT~

(4)

(3)

(2)

(1)

<p~'#li~

Relationship with Member

(5)

(6)

GWlI

Note: If any child is physically handicapped, please indicate "DISABLED" below his/her name.

13.

14

~
mm

<t'l ~
~

<t'l ~

ffi'

<PT "fT1{/

m) IDate of death of Member (ifapplicable)

I I I I I I I

<PT f<tcRuT /Details of Bank Accounts Opened

Name of the Bank

<PT "fT1{ I Name ofthe Branch

'l'l 6ICfi l:jffi'1 Full Postal Address

~
q;);s I Pin Code

(~~

# ~/~

-am ~ ~/~

rf; ~/

'tII;iIt 1llI!'
lIftt~

Signature

Form IOD (www.epfindia.gov.in)

eR

Please attach a copy of cancelled/blank

of member/applicant

Cheque)

f./tiI1mr ci; ~/

Signature

Page 2 of6

of Employer

'fi. ~.
SI No

~/~1'ffl"'Wf/

"ifim. tq; -mm ~. /

Name ofClaimant(s)

Saving Bank Account Number

m~

GT<IT fcIrn\ "'Ilf>rff <ZIfcltr "[RT ~

fclxrr 7J<IT ~
(a) If the claim is preferred by nominee, indicate hislher.--

14 . .A (c!i) ~
(1)

15.

Name

'Wf/

(2) ~

Wll"f

---...,

L..

ct; ~

~/

1'ffl"flm"ur

m~

.,-

tr

Cffl ~

m}

~
ct; tjffi
cfflt
Detail of Scheme Certificate already in
Possession of the Member, ifany

en ~/ifReceived,

'fi. ~.
SI No

16.

m'<f ~

m'<f

Indicate:
~.

Authority who issued the Scheme Certificate

m.,

(~et;

~/

2.

l\l.l\l.31T:if.

et. rvr. /

\3'. et. <!iT. "[RT-;;ffi)

Issued by RO/SRO

PPONo

Documents enclosed (Indicate as per the Instructions)

4.

1.------------_

3.

D
D
D

Not Applicable

~
q;. if.
1995 ct; 3Rf1fQ ~ \iIT 1(jft ~
Ifpension is being drawn under E.P.S, 1995

fclxrr

Not received

-;ffi) /

Scheme Certificate Control No

17.

"fiofr.f

Scheme Certificate received & enclosed

"ffil! ~

~"SIT'<!

-\

Relationship with deceased Member

5.

6.

fiImr vmrr ~ I Certified that;

mwrr, 1995 et; ~
iWf ;ffil ~ W tl
I am not drawing Pension under Employee's Pension Scheme, 1995.

0)

i'f ~

Qi)

tf?[

"4 ~

flm"ur ~

-mt t I

The particulars given in this application are true and correct

~lDate
~lPlace

~
et; ~
<rn 6W <t'I 3t'!,OT f.mJ;ft
Signature I Left Hand Thumb Impression ofthe applicant

~ ~/SigDature
f.\1I)1ft!y/~

Form IOD (www.epfindia.gov.in)

of Employer ~
~

Page 3 of6

um 'Rf 'GIRr t)

(TO BE FILLED UP BY THE EMPLOYER!

AUTHORISED OFFICER OF THE ESTABLISHMENT)

Fcmrr

lIJ!IfiIRr

1.

\lJJill ~ ~ /

Certified that:

~<IiT~mlHI

The particulars of the member are correct.

2.

~
q\\ ~
~ ~ ~ 12 ~
q\\ ~
<liT~
~ iWt ~
<liT~
I
The particulars of Wages and Pension Contribution for the period of 12 months preceding the date ofleaving service are
as under:

~ ~

wfi

Tj ~

12 ~

<Cl 'It ~

m 12

'Ilft;IT

ifj[ ~

-31f.<rq "ill<

JlNI'l{ ~

(in case, the wages are not earned for all 12 months, the block of 12 months will commence backwards from the last pay
drawn)

<i't
Year

~/

Wages

"" ai"mTIlt ~

~1llA~

Month

Pension
contribution due
~q\'t<'i.
No. of days

ww

<I>ltffiuT I

mG..~

~~~tm~GW'f
Details of period of non- contributory
service. If there is no such period,
indicate 'Nil'
"lfIf/ Year
~q\'\<'i.~~~

Amount

3lAAcr ~

q\\

no. of days for

which no wages were

'It/

earned

(2)

(1)

~
I.~

(4)

(a)

(5)

(6)

(7)

: Enclosures:

-q ~

2.~q~uilCi1q>~

~/

Docurnente
~

""flT ~

ifj[

as given in the Instruction

"If'BI/Form of descriptive roll and specimen signature

~i!\"~/~~
~lDate
~fplace

Form IOD (www.epfindia.gov.in)

"$ ~
~ ~
ft'IIIIN
Signature of Employer! Authorised Official
of the Establishment with Seal and Date

Page 4 of6

~~1ffiI~~<f;~"'I~

(To be submitted

-M't <fiT fc'fcRur aIR ~

Descriptive roll of Pensioner
l.~

2 ~"'Ilffi1O~\iIl\[)

in duplicated

~/~

in respect of each person eligible for pension)

f.rnT'l

and his/her Specimen

SignaturefThumb

impression

<fiT "'frI{/Name of the Member

2.lI>.'l'f.f.'t. ~

3.m

<'i./E.P.F

1Wft<fiT

Account

Number

"'frI{/Name of the Pensioner

4.furr/l!fa <fiT "'frI{/Father'slHusband's

Name

5.fwT/ Sex
6.~/Nationality

7.q4/

Religion

8 :wmV Height
1

Personal

Marks ofldentification

Specimen

II.~

signature

f.Rffi" ~

of pensioner

-M't) ~

~/
Place:
~/Date:

Fonn 100 (www.epfindia.gov.in)

1 .........................................................

qlt cmr 1{ ;ml ~

[Only in the case of illiterate Claimant

~/THUMB

~/INDEX

(Pensioner)

<f; f.rnT'l.
Left Hand Finger Impression]

qlt ~

"It2PIT1 MIDDLE

~/RING

q;f.rerl

~/
~~<f;"'frI{~>ITiR
Name of the Attesting Authority

Page 5 of6

SMALL

Signature
Official Seal

~~~~)
(FOR OFFICE USE ONLY)
(tl'wi 3Fj"1I'T /mm 3Fj"1I'T)
(pENSION SECTION/ACCOUNTS SECTION)
WlTflIRI ~
iiImT ~ ~ ~
~
Tj ~
~
<!iT ~
~
~ ~
WIfCI"'f <IR fRm 7fm t 1 ~
~
tg 'lBI t 1 3lJqif; ~
~
~~~)-;jh)~~tl
Certified that the particulars in the application have been verified with the relevant concerned documents, the claimant is eligible for
Pension. The Input Data Sheet is placed below for approval:

("4. tft.) 'ffiC< mm ~/GTQI

3lJqif; ~
~ ~
<IR <'ft ~ tl
Entered in Form 91F0rm 3(PS). Master Ledger Card! Claim Inward Register
~&m~~~~~-2
(3lRl~tl
Form 2( R) enclosed along with the documents furnished by the Claimant.
~-9/lI1rn-3

'ffi.~.~./ S.S.A.

3lj. ~/

~/Date

~/Date

~.~. ~./

S.S.

~I

A.O.

~.'f.f.J.arrg(/tffi)/ A.P.F.C.(Pension)

~I

Date

Date

~"ff'!"lmsn~<t;~
(FOR USE IN PENSION PRE-AUDIT CELL)
~

srer ~

~ ~

~ <If.!I~

am -mT tJr!lT7fm t 1 ti. 3RWft

'lm ~

<IR ~

3l$T

q;'t ~

&m "1hrn

<IR~V!T1;[1

The Input date sheet verified with reference to the application and the documents enclosed and found correct. P.P.O may be
generated through Computer.

,b~./A.o.

~/S.S

'ffi.~.~./SSA

3lj.

~/Date

~/Date

~.'f.f.!t.arrg ~)/

~/Date

A.P.F.C.(Pension)

~/Date

(/tffi flI<Rur ~
~ ~)
(FOR USE IN PENSION DISBURSEMENT SECTION)

Tt

31. 31.

"fi.

P.P.O.NO.
UJRt <IR'l ctft ~
Date of issue to the Bank

ta>

ltcI; lIi't

Bank

lIi't ~
<f1!IT mm 3!'J'WT q;'t ~
UJRt <IR tt ~ ~ 1
Intimation sent to the Claimant and also to Account Branch on

'ffi.~.~./ S.S.A.

3lj. ~/

~/Date

~/Date

Form IOD (www.epflndia.gov.ln)

S.S.

~.~./

~/Date

A.O.

~.'f.f.!t.arrg ~)/

A.P.F.C.(Pension)

~/Date

Page 6 of6