Emp21D: 50850 ‘Serial No: For Ofice Use Only In Wards No, Form No. 10 ¢ (EP.5) EMPLOYEES’ PENSION SCHEME, 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHORAWAL BENEFIT/SCHEME CERTIFICATE 1a) Name of the member ~ -S2VA KUMAR BO (in Block Letters) 'b) Name of the claimant (s) SPA KUMAR BR _ 2 Date orsinth Cl) Gee 3.) Father's Name —Adéinaxayona A b) Husband's Name 2 (fappicabe) 4 Name & Address ofthe Establishment inwhich, the member was last employed 5 Code No & Account No. RegioniSRO Codd OIL ]14%453551 Estt. CodeNo, __ Alc No l ©. Reason for leaving service —Resignition 8 Date ofteaving oO — td 7 fubposial Address = OYA KOMAR-B. Yo, ADLNARAYANIA 8 {in Block Letiers) 5 ‘ShiSmt.km. , MECAPUROM, Si0, Wie, Dio “AM DEa Peanecy PIN8 Are you wiling to accept Scheme @ ) Certificate in ie of withdrawal benefits Yes! Noh 8. Particulars of Family (Spouse & Civiren & Nominee) Bhrawctth? Ran? & Name Date of Bith Relationship \wth Member _ Name of the quardan of minor flamers 8-C6-%R Spout (®) Nominee 10. Incase of death of member after attaining the age of 58 years without fling the claim (@) Date of death of the member (b) Name of the Ciaimant(s)/ and relationship with the members 31. MODE FOR REMITTANCE [PUT A TIC IN THE BOX AGAINST THE ONE OPTEO] (2) By postal money order at my cost to address given against item No. 7 (Azan pre cue at res er cot. 8 ene Ba i ios tome a oe S.B Accounts No Odo lO1IO A7OC4H Name of the Bank Axts BANK (inbiock letters) 7 Branch ECTOR - | (in block ttters) Ful Adéress OF te Brench x; - B3 (in block letters) "4 ECTOR=I O1DA, E 01 301 a 12 Are your avaling pension under EPS-06 soindicate PPO NO. By Whom Issued CCortified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE, /,.»%, sidhie ore Hana Tndf Impression ofthe ‘ Member / claimants) Date.ADVANCE STAMPED RECEIPT [To be furnished only in case of (b) above) Received a sum of Re. (Rupees. Only from Regional Provident Fund Commissioner /Oficer-in charge of Sub-Regional Office. by deposit in my savings Bank A/c towards the settlement of my Pension Fund Accounts. (The Space should be let blank which shall be filed by Regional Provident Fund Commissioner /Officer-in- charge) ‘Signature & lef hand thumb impression of the member on the stamp 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 as under:- Form 3A/7 (EPS) enclosed for the period for which it was not sent to employee's Provident Fund Office) ‘Wages (Basic + D.A) as on 15.11.95(if applicable) Wages as on the date of exit Period of non contributory Service YeariMonth ‘No.of days: Date. Signature of Employer’ authorised Official(FOR THE USE OF COMMISSIONER'S OFFICE) (Under Rs, P.LNo M.O./Cheque Passed for payment for Rs. (in words) §M.O. Commission (it any) net amount to be paid by M.O towards withdrawal benefit, DH ss AAO (FOR USE IN CASH SECTION) Paid by inclusion in cheque No. ot vide cash Book(Bank) Account No. 10 Debit iter No. DH ss AC(Ales) Forissue iS: IDS is enclosed DH ss A.AOIAPFC(Alcs) (FOR USE IN, PENSION SECTION) ‘Scheme Cerificate bearing the contro! No. Jssued on and centered in the scheme Certificate Control Register DH ss AKO APFC(PENSION)Employees’ Provident Fund Scheme, 1952 Form-19 (Refer to instruction), am 1._Name of the members in Block Letters. SIVA KOMAR B 2 Fathers Name or (husbane's Name inthe case of marred woman) 1» B 3 Name 8 Adress of the FactonEstabishment ‘was employed. in which the member _ 4 Account NO. DL 1699.5 13551 5 Datecteaingsevee —30- Sep -d010 & Reason forleavng service Ratgraton 7 FullPostal Adeess (in Block Address) ‘ShaiSm Kum SIVA KOMBR: B ‘Se DEAS RAYA NA: B DEORNd:RE-4~ 1483, SADACIVA NAGR, cama MEZA PURUM, HEAiDUPOR : ANANITA POR (DIST) ~ ANDHRA PRADESH ~ SL s]alol'] 8 Mode of remittance Put a ick (1) in the box against the one opted (3) By Postal Money Order at my cost fd To the address given against tem No. 7 (©) By account payee cheque sent (7) $B Aesmunt Ne. G0 106041005 Direct for credit to my S.B. Name oe acc AH. MALS BAN IC, ‘Aic (Scheduled Bank/P ©.) Branch... beet st =16. , ste OP, Under intimation to me. Fuses ofthe ranch ASS GANG, 82-63, KCIGr Anica, OP, golte! (Advance Stamped Receipt furnished) Certified that the particulars are true to the best of my knowledge Date ojoring otEstabisnent... 25** Aug afoot, ate orBitn LO Moy Ret 14.77, Contribution for the Current Financial Year Period of = Month Contbution_|_ break any Monin En Em Tost Month | Wages, (Month | Wages epr_|relepe |r |err | ep EEoo - as (nfermation to be fumished by the Employer ifthe Claim Form is Attested by the Employer) Certified that the above contributions have been included if the regular monthly remittances, The Applicant has signed/Thumb impressed before me. ad Signature of LefvRight hand thumb ittbression of the meitoer Date, Designation & Seal Ene! Declaration of non-empioyment 'Note:- In the case of submission of application for settlement under clause (s) of sub-paragraph () and in clause (b) of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1952, the claim should be ‘submitted after two months from the date of leaving service provided ber continues to ‘emain unemployed in an establishment to which the Act applies. Date. ‘Signature or Left/Right hand thumb impredsion of the member ‘ADVANCE STAMPED RECEIPT (To be furnished only incase of 8 (b) above) Received a sum of Rs (Rupees ftom Regional Provident Fund Commissioner / Officerin-Charge of Sub-Accounts Office by deposit in my Savings Bank account towards the seitiemient of my Provident Fund Account ‘The space should be left lank which shall be filed in by Regional Provident Fund Commissioner/Officer in-Charge of SAO. ‘Signature orteft/ Right hand thumb impression of the member (For the use of Commissioner's Office) ‘AIC Settied in part Full Entered in F. 21-A/24/219 & withdrawal register ‘Section Supervisor Pine: —= MO7Cheque ——— ‘Account No. ———-——~_Seetion passed for payment for R's-———~- Tie wat ‘M.O. Commission (it any) AOCIAPFO——————— [Net Amount to be paid by M0. se ED (For use in Cash Section) Paid by inclusion in Cheque No. 4 date, vide Cash Bock (Bank) Account No.3 Debit Item No C He AC /RC RemarkswO22BBbw 21020200N O22,80" 32