Ack No.

230302152026000789850

Application Form for validation of Joint Options

[ From the employees who had retired before 01.09.2014 and exercised joint option
under Para 11(3) of EPS Scheme prior to 01.09.2014 ]

To be exercised by eligible members of EPS-1995 on or before 03rd March 2023 with reference to Para 44(ix) read with
Para 44(vi) of order dated 4.11.2022 of the Hon’ble Supreme Court in SLP No. 8658-8659 of 2019

DISCLAIMER
I have gone through Supreme Court Judgement dated 04.11.2022 in SLP (c) No. 8658-8659 of
2019 and I am registering the application in terms of directions contained in the said judgement. I
undertake that the pension will be calculated subject to formula determined under the Scheme.

Place : ALLAPALLI

Date : 06/03/2023

Sl.No Details

1 PPO Number NGNAG00070826

2 PPO Date 31-OCT-2008
PRABHUDAS Z ATRAM
3 Name of Member (as per PPO)

4 Gender Male
5 UAN No. N/A

6 Date of Birth of Member 01-JUL-1950

ZUNGRAJI
7 Father’s / Spouse Name (as per PPO)

8 Office by which PPO was issued NAGPUR

9 Service Details
Date of joining Date of leaving Date of joining Date of leaving
PF Account Number Establishment Name
FPS FPS EPS EPS

NGNAG00169750000009 DIVISIONAL
9.1 02-FEB-1972 15-NOV-1995 16-NOV-1995 30-JUN-2008
463 MANAGER (F.D.C.
Date of Superannuation
10 30-JUN-2008
(applicable only if date of filing joint option is before 01-09-2014)

Date from which employer’s contribution was received on wages

exceeding statutory wage ceiling of Rs 5000 in EPF prior to
01.06.2001 from the day his salary exceeded Rs 5000?
11 16-NOV-1995
(applicable only if date of joining is prior to 01.06.2001)

Whether Employer’s contribution was received on wages

exceeding statutory wage ceiling of Rs 6500 in EPF prior to
01.09.2014 from the day his salary exceeded Rs 6500?
12 N/A
(applicable only if date of exit is on or after 01.06.2001)

Date of filing joint option under the proviso to Para 11(3) of

EPS Scheme?
13 Please attach the copy of joint option form. 16-NOV-1995

(applicable only if date of filing joint option is before 01-09-2014)

14 Date of rejection of joint option by EPFO. Not Available

Office by which rejected
15 N.A.
Please attach the copy of the order of rejection.

16 Aadhaar No. of Member XXXX XXXX 7339

17 Aadhaar linked Mobile No. of member 9403398570
SBTINFC@GMAIL.COM
18 Email ID of member

19 Aadhar linked Bank Account no. 960510100011349

20 IFS Code BKID0009605
Whether member wants to use accumulation available in
21 his / her PF account for payment of due contribution for this option? No

22 How much is the PF account balance on the date of filing option? N.A.
Whether member is giving undertaking to deposit the contributions
23 along with interest due till date of payment through his last Yes
employer [only when PF account has no / insufficient balance]?

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 Ack No. 230302152026000789850

Declaration:

1. I hereby declare that I have read and understood the Supreme Court Judgement in SLP (c) no.8658-
8659 of 2019.of the Hon’ble Supreme Court and I am registering this application in terms of the
directions contained in the said judgement.

2. I understand and agree that as a member of the Employees’ Pension Scheme, my rights to claim
pension are limited to the scope of judgement and within the EPF & MP Act, 1952 and the Schemes
framed thereunder.

3. I further understand that the central government is empowered to amend the scale of benefits,
commensurate with the contributions made, either prospectively or retrospectively, on which the
pension payable to me shall be computed.

4. I do hereby agree that the details of contribution and interest given by my employers are essential for
the computation of dues payable for this application, and this is the full and final submission.

5. I hereby certify that the services details in the above form are correct and no material fact has been
mis-represented or hidden by me.

6. I hereby agree to pay due contribution in a single tranche as specified by EPFO, along with interest at
rates declared under Para 60 of EPF Scheme 1952 or at the rate declared by the concerned trust of
such establishment, from time to time, whichever is higher,if any.

7. I hereby jointly apply along with my employer to pay full amount of contribution on salary exceeding
wage ceiling under erstwhile para 11(3) (since deleted) of EPS 95 along with interest upto the last
date of the month in which payment is made, in accordance with the judgement dated 04.11.2022 of
the Hon’ble Supreme Court through my last employer within such period as directed by EPFO
after validation of my application. If the full amount payable is not deposited by my last employer
within such period as directed by EPFO after validation of my application, this application
shall be treated as Null and Void.

8. I undertake that all the facts are true. If the details submitted by me or my employer are found to be
incorrect at any point of time, this application shall be treated as Null and Void.

9. I am aware that in case of false declaration and willful mis-representation, appropriate penal action
may be taken by EPFO against me.

Place : ALLAPALLI PRABHUDAS Z ATRAM

Date : 06/03/2023

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 Ack No. 230302152026000789850

Declaration by Employer

1. I have verified and hereby certify that the details provided herein above in the
application form by the aforesaid employee are true and correct.

2. I hereby declare that I had jointly opted with my aforesaid ex-/current employee to
contribute on
salary exceeding the wage ceiling under erstwhile para 11(3) (pre-amendment) since

3. I hereby undertake that if any of the details given above are found to be false, the
application shall be deemed to be rejected.

4. I am aware that in case of false declaration and willful misrepresentation, appropriate

penal action may be taken by EPFO against me.

Place : ALLAPALLI Authorized Signatory

Date : 06/03/2023 VARSHA WASUDEO MADAVI

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Signature Not
Verified
Signed by :
Date : 06/03/2023 13:58:05
Reason : eSign Service
Location : India