UAN : 100114673712

Mobile Number : 9923019291

Tracking Id : 10011467371203001
IP Address :106.220.224.86

APPLICATION FOR MONTHLY PENSION FORM-10D (E.P.S.)

(EMPLOYEES' PENSION SCHEME, 1995)

1. By whom the Pension is claimed? : Member

2. Type of Pension Claimed : Superannuation

3. a) Member's Name (In Block Letters) : BILLU SHRAVAN WALMIK

b) Sex : Male

c) Marital Status : Married

d) Date of Birth (dd/mm/yyyy) : 24-05-1959

4. E.P.F. Account Number : MHBAN00012510000103112

Name of the Establishment in which

5. : M.S.E.B.
the member was last Employed

6. Date of Joining in current Establishment : 16-11-1995

7. Date of Leaving Service : 31-05-2019

8. Reason of Leaving Service : RETIREMENT

AP POPHALI MSEB COLONY CLASS 4,BUILDING NO 7 ROOM

9. Address for communication
NO 69,CHIPLUN - 415601

10a. Opted for reduced pension : --NA--

11a Deferred Pension : No

12. Particulars of Family

Sr. Guardian's Relationship with

Name Date of Birth Relationship with Member Guardian Name
no. Member

1 01/01/1971 Wife --NA-- --NA--

KAMLESH BILLU
VALMIKI

13. Details of Bank Accounts Opened :

1. Account Number 148812110000164

2. Name of the Bank BANK OF INDIA

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 3. Name of the Branch SHIRGAON BAZAR (IFSC : BKID0001488)

Full Postal Address

4. MAHARASHTRA
Pin Code

Detail of Scheme Certificate already in Posession

14. : No

Sl No Scheme Certificate Control No Authority who issued the Scheme Certificate

-- --NA-- --NA--

15. Documents enclosed

1. Photo 3. Cancelled Cheque

2. Family Details 4. ---

Certified that:

(1) I am not drawing Pension under Employee's Pension Scheme,1995

(2) The particulars given in this application are true and correct
(3) In consideration of your having, at my request agreed to make payment of pension due to me everymonth by credit
to my account (as refer in 13.1) with bank (as refer in 13.2), I the undersigned, agree and undertake to refund or
make good any amount to which I am not entitled.I also irrevocably authorize the bank to recover any such amount
credited to my account to which I am not entitled by debiting my said account or any other account/deposits
belonging to me in the possession of the bank against any claim made by RPFC in this regard.I further hereby
undertake and agree to bind myself and my heirs, successors, executors and administrators to indemnify the RPFC
against any amount credited to my account to which I am not entitled.

Cancelled Cheque :

Date : 30-Nov-2022 18:49:25

Place :

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