Ack No.

230518134754014788440

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 26th June, 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 : KONDAGAON

Date : 18/05/2023

Sl.No Details

1 PPO Number CGRAI00018956

2 PPO Date 28-JUL-2006
MINTU KUMAR DAS
3 Name of Member (as per PPO)

4 Gender MALE
5 UAN No. N.A.

6 Date of Birth of Member 14-JUL-1948

R.G. DAS
7 Father’s / Spouse Name (as per PPO)

8 Office by which PPO was issued RAIPUR (CHATTISGARH)

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

CGRAI001718600000000 CHHATTISGARH
9.1 N.A. N.A. 16-NOV-1995 13-JUL-2006
30 RAJYA VAN VIKAS
Date of Superannuation
10 13-JUL-2006
(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. 31-AUG-2014

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

14 Date of rejection of joint option by EPFO. N.A.

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

16 Aadhaar No. of Member XXXX XXXX 2834

17 Aadhaar linked Mobile No. of member 9406362874
MANISHDASKGN@GMAIL.COM
18 Email ID of member

19 Aadhar linked Bank Account no. 11242737322

20 IFS Code SBIN0001265
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]?

Page 1 of 2
 Ack No. 230518134754014788440

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 : KONDAGAON MINTU KUMAR DAS

Date : 18/05/2023

Page 2 of 2
 l

rq lo zlzo23
*-l
Data: /

To
The Regional Provident [und Commlssloner,
Employees Provident Fund Organllatlon,

para r1(3) of Ernpbyccd Pcruim s<ficrnc, rBs in comgliance ol ciranlar

sub.: submission of Joint option undcr dcleted
d.tcdz:rc3-zolrbCl|GdbYEPf,orfaimplerncrin:drci*nartdLo''lD2ol6olthr-'lorllcSt'Ptltltccourrln
ln a.A" No. 008143'O@1'L l 2022titled
&C Gupta vs. UOt 12020) 13 SCC SOO an; in. Srpr.r" iourt fudgemeil
"EPFO vs. SUNIL I(UMAR 8.'pronounted on o4'l,l'2022'

.Sir,

paying tnhanced- revised pensicn after getting return of differeritial

ln pursuance of aboye cir6ularr EpFo has been pre 0L'09'74r4
g.1?% of.ar.ri.r.rv ini issx of ceiring amount wi& interest from the
amount i.e., difference between 0+tl-2022 in EPF, vs'
rerirees upon exercising jcint option under dereted
?aia 11(31. vide supreme lourt Judgment dated
judgment has been upheri and EpFo has been directed to imprement the same
Sunir Kumar B & ors., ttre ntio of R.c. Gupta
w,ithin 8 weeks.

z3'03-2017, yetvide another circular dated 31-05-2017

without
Arthough ap the retirees were covered in circular dated pension only for pensioners
pension Division of EpFo restricted the benefit of actual salary
any approval {rom cBT and MoL&8, has unequivocally held'that
from unexernpted estabSshments. The Hcn,bre supreme court vide judgement dated 04'11'2022
g*.*x"a since they
estautistrmentt and Un-exempted establishments
rhere was no distinction between the emplayeer ui
stand on equal footing for EP5'95'
Hon'ble supreme
deleted Para 11{31 of the Scheme is concerned' the
so far as the question of exercising option under Hon'bre Supreme court
reJterated the decision in R.c. Gupta case. The
court in para 41 of the judgment dated o4-11.-Zl22has already benefitted by the earlier
ercluded pre 0149-2014 ietirees from the operation
of this judgment since they stood
j-c6,.ne.rrcated@-l020t6renderedinR.cGuPtacase"Thepreor{}zol4retireeswer€mtimpaaedbYtheGSR5'@dated
ofd€r'
their righs stood already crystallized under the ertier R'C G{JPI'
2248-2At4 aod

yet been prorided by EPfo {also not avall'l:T EPFo,s website),

based 9n
Since no forrnat for the,oint option has
judgemen$ in order to
the ;;;;;toir g zora while tmplementing th. RC Gupta
simirar formars ir*ued av r"ri"*io iftipoin under
w" are, hereby $.,hmitting the ioint option as required
compry with thq,above requirement {emdoyJe-rial*ntprov.r} inrtead of ceili4 salary
pensicn puntion ott .*tual ilary/waget
s.#;-;;il;;iJi,rlng
erstwhire para 11(3) of Emproyees,
limit of Rs. 5,500/'{earlier Rs' 5,000/')'

under:
My particulars ( retired employee ) are 1s

of Retlred
1. rrr;e a Uetgrution
emptsYrE
MrNTU KUr.ttr&_bA€-
2_ Father's name I SPouse'r narae t-r}TE @
3. Date of Blrth l+- 48--
o7":_1_5
4. EPF A/C No. ;qn?Leelro
5. PPO No,

b ulilTffiElfiit a ppt ica ute )

, Aadhaar No, 463t84 80 2834-

8 Mobile No. 37_+69 Sz9+1 J
 I

'9. Date of retirement ton ittainlng 58 56} !te-a*3

years) / Datt of voluntary retirernent
l*t thp aqp of Years)
31-O7- 2,W4
10, E;mall address
rnsTtish"("sk@
11. Sesldentlal Address 'PrQ* ,b
D,isrf KH.do'A-erDb e's'-) TsaA
pEcunAnoN ?fiHE RITIFEE

.t
It is certified that immediately after joining
-
. : :
had been contributing towards the Plovident funA on mV ictualsalary/w'gil-ta t-' "q*i tl"*G:.'.t"-1:1tt-t:::i'X:":r::,"
ff}T;Tffi:;:Jil;;il;i ;ili;& z6{6ior EpF scheme, risz, rt rs to rurther
certirvthat rn amount @8't?%
had been remitted by my
of the statutory ceiling limit i.e., 6,500/-
Rs. tq.if io ii]
i,OOO/-l ou, of the Employe/s contributlon
'''
employer every month towards Employees' Pension Scheme'
1995'
retir:menl
5-r r hilG .kc.dr uihdriln rc cntirt .mll d P'qdrlcr* Frrrd qr mY rfiittfitc'lrrt'dur*arv
ltih'lst'di 1l- dt'
I

undertahc to rchrn o,. dr! dificrerrtll rrrognt trt ir* *ilrf"*r, cu w nrfrrrrailuorrrrytryads P.endon Fund and
difference between the amount @g.33t6 of :ny *r.rylt*go out of crnpfrovcr's contrlhrtirn
".a*i s.l.rvlwagii from the date -of ibirilrii rhe EP$95. till mv
the amount arready remitted byale emprov., in iil;is L'i ..nlng
attaining rhe age or ss y"r* l-Eg*v"I" iJr. ,.' *v *Juntr.y
i.tirer*nt)Lith due interest for claiming nry eliglbilitv for
on ceiting ralary/wages in accordance with the
aforesaid
drawing pension on the u.ii, ? rfr.r ,udrvl*i-*'iir[ii-"i
judgements'

before 01-09-2014 i.e., or

#fi l#i;:"1ffi:,H;lj;[l'$f*ffi1]
:'iJ::ililj:';;':ff once
of the same may be proriart Tt' *idy to submit the same agaln'

Signature :

Name: MrNT u Ku,banR D+s

Address:

'1,
- r Oesignation)
,
l*airr
i -,-
rr,olitt
ttt;
' : ' '
orized:riEnatpfy-On behalf of b
(Name and ^--i--;a!^-t bflgt
i'#fii"8;;at6f--v
doherebycertiiithat5hri/Mrc./Ml3/,after53years{duetohis/her *g!s Y'tl.:: workins

20;6 :;;ffi;;;il'-;';;' acr/ tzi B5l =o --'-. "-' ---'-T{1:

voluntaryietiremen|}onJa[ut|4Uu\5.nl}/llE|Lrt'vl.'-.'.--ffis(s)ottt,eEPFScheme
=1lsEl
been contributing towrrds Provroent
r!r.u err ' a*ahr<hment
had :X':.,'iil;;;'r;;_
hadbeencontributingto'ffi;il;;tt';".11:ln:l^t-1,',-1:*l{::tt*rr
estaulishment too' Thls obiection if
has no obJection
establlshmenl has If he/she
had';;;; ;;;,ribured bv thii
1952. Equal share date of co_r4menrfment of the ssheme or when
arnount.w,".?. rs-ir-rgss i,e. from the
deposits/returns the due differentiar scheme' 1952 from time to
aiong with due lnterest as declared.under EPF
hisy'her satary/wages .r.#;;;l+,r1*"y1i11, pensronabresarary-b*red on hisrher actuar sarary/wa,es,
t*draruingpeJs*"rir,i ryirof
time, thus makinS.him,/&"r"*eiar"
p-.1:r::ylireriir ,(:l of the Epi'e' scheme as permirted to do so by the aforesaid
insread of on the ur,uro.iltiiil-r,
iudeement of Supreme court dated 04.10.2016 imil;;;i by EpFo vide circurar drted 23'03'2017 aftar due
approval from

iriiis-ri-2orei a uotaE (16-03'2017)'

lcertlfylhattheparticularsfurnishedabovearecorrectaspertheava]lablerecord,
':-

Date:
seal)
(Slgoature of authorized rignatory with officiat