Serial No: For Office Use Only In Words No. Form No. 10 C (E.P.S) EMPLOYEES' PENSION SCHEME, 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFITISCHEME CERTIFICATE (Read the instructions before filling. is form) a) Name of the member (In Block Letters) by Name of the claimant (s) Date Of Birth a) Father's Name ) Husband's Name (fepplicable) Name & Address of the Establishment In which, the member was last employed Code No. & Account No. Reason for leaving service & Date of leaving Full Postal Address (in Block Letters) ‘Sh/SmtKm li Regioni$RO Cod: Estt. Code No. Alc No. Slo, Wo, Dlo PIN,8. Are youwilling to aocept Scheme @ © Cerificate in lieu of withcrawal benefits Yes No| 9. Parliculars of Famiy (Spouse & Children & Nominee) Name Date of Birth Relationship With Member Name of the guardan of minor (@) Family Members (b) Nominee 40. Incase of death of member after attaining the age of 58 years without fing the claim:- (a) Date of death of the member: (b) Name of the Ciaimant(s) / and relationship with the members 11. MODE FOR REMITTANCE [PUT A TIC IN THE BOX AGAINST THE ONE OPTED} (@ By postal money order at my cost to address given against item No. 7 (0) Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimatior tome SB. Accounts No. Name of the Bank PeEEEHE Hee Heer eeeeeeeeeeeeeeee eee er (in block letters) Branch ee {in block letters) Full Address Of the Branch {in block letters) 42. Are your availing pension under EPS-95 ? Ifs0 indicate PPONO,. By Whom Issued, Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE Date. Signature or left Hand Thumb Impression of the ‘Member / claimant(s)ADVANCE STAMPED RECEIPT [To be furnished only in case of (b) above] Received a sum of RS... ernneARUPECS.. Only from Regional Provident Fund Commissioner /Officer-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 left blank which shall be filed by Regional Provident Fund Commissioner /Officer-in- charge) Rel. Signature & left hand thumb impression of the member on the stamp Revenue Stamp Certified that the particulars of the member given are correct and the member has signedithumb 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(it apy Wages as on the date of exit Period of non contributory Service ‘Year/onth No.of days Date. ee Signature of Employer! authorised Official(FOR THE USE OF COMMISSIONER'S OFFICE) (Under Rs. ere PLLNO sn M.O,/Cheque Passed for payment for Rs. seven snensen Qh WOES). e MO. Commission (Wf any)... -esnesnesnnnee@t amount t0 Be paid By MLO. ssrrne towards withdrawal benefit \ DH. SS AAO RL (FOR USE IN CASH SECTION) Paid by inclusion in cheque NO......scsen No. 10 Debititem No. vide cash Book(Bank) Account DH SS AC{(Alcs) For issue if .S;, IDS Is enclosed. DH 8s A.A.OIAPFC(Alcs) (FOR USE IN PENSION SECTION) ‘Scheme Certificate bearing the control No. nee selssued On... and entered in the scheme Certificate Controt Register- Ll DH 8s AAO APFC(PENSION)To Full Name: ‘The Trustees Bajaj Auto Limited Provident Fund Address: Aku, Pune 444 035 Mobile I Email Dear Sir, | hereby declare that 1 am not in the employment of Bajaj Auto Lid / Bajaj Finance Ltd from ‘and hence | request you fo pay the amount standing to credit in my Provident Fund in ecordance with the rules of the fund by following manner: Bank Account Details Name as per Bank Account Name of the Bankibranch Bank Account No IFSC code: (Please enclose @ cancelled cheque /copy of bank passbook) Date: Signature NON-EMPLOYMENT CERTIFICATE solemnly declare that | have not been employed in any Factony/Estabiishment to which Employees’ Provident Fund Act, 1952 epplies, for a continuous period of not less than two months immediately precading the date of ‘my application for final withdrawal of the amount standing to my credit in my Provident Fund Account. Signature CERTIFI EMPLOYER 4. Name: 5. Period of Service 2. Ticket No. : 6. Reason for Leaving 3, Date of Joining 7. Date of Clearance 4, Date of Leaving : We cerlfy that the above details and sianature are as per records /documents available with the company. Signature: Name ‘Company Seal Designation : RECEIPT Received with thanks from Bajaj Auto Limited Provident Fund the sum of Rs, through bank transfer dated J by Cheque No. dated on | towards the fal & final settlement of Provident Fund dues. et i Reverse Name simp Ticket No: Signature