~ W'/ Mobile Number

{IRt;r ~ ~ ~/ For Office Use Only

1U1I T ~/CI 8m I .D.......................
~ iftFf q~ ~104l (iI;:lf:~.)
APPLI CAT I ON FOR MONT HLY PENSI ON FORM-I O-D (E.P.S.)
~mt~.11l96
(EMPLOYEES' PENSI ON SCHEME, 1995)
~ I N'J I cm ~ if 1I 1f ~ ~/(Read I NST RUCT I ONS before filling I n this Form)
1. fcml' et; &m WrI <PT ~ ~ mn t ?
Bywhomthe Pension isclaimed?
2. GT <I l ~ 'l{~ <PT W/iR
T ypeof Pension Claimed
(q) \jfi'<J ~/3mj/Date of Birth/Age (dd/rnmlyyyy)
1 1 1 1 1 1 1 1 1 1
3. (C/i) ~ </iT "'fl1f ~ 'lI 1l'Rf 1l) Member's Name(1nBlock Letters)
(<if) 1Wr / SEX:
T ) ~ ~/Marital Status
@ ") furr/'lFct </iT "lJ 1'I /Father's/Husband's Name
4. C/i. "I f. f.I . Wffi "ffi:lm/ E.P.F. Account Number
>P T
OFFI CE
mo.rRm "'I .
Establishment Code No.
~ <PT ffiCI T "ff.
Member's Ac.No.
5. ~ </iT 'Wl" q'I T v~ &'<f -l( ~ t.lT
Name& Address of theEstablishment
inwhich themember was last employed
7.
mrr ~ ~ ~ / Date ofleaving Service (dd/mmlyyyy) : 1 I 11 1 11 1 1 I 1
~- - ~~==~==~~I
6.
8.
mrr ~ </iT <I iR"T / Reason of leaving Service
'l?! ~ ~ 'lOT / Address for communication
(a) I ncaseofreduced pension (opted date
for commencement of pension.)
~/Date lffl\"/Month
qrf,lYear
~/~ ~ "iffi'llffi/Signature of memberlapplicant ~ et; "iffi'llffi/Signature of Employee's
Form lOD(www.epfindia.gov.in) Page10f6
9. #-mt et; 1/3 'lflT et; tfl~I J lqCj)~OI i!jf fi't<I ;(;q
Option for commutation of 1/3 of Pension
~ 1f;<! 'I I NifflCj)~ol et; ~ ~ ~ '1<lTm<I T
-mt"CI >T ~~
(I f option is for lesser
Commutation indicate the quantum)
~ IY es "'lift INo
, - - - - - - - , I D
If Y es, Quantum
10. #'i'l\'\ <t'l ~ ~ fi't<I ;(;q [(./) ~ WT flf]
Option for Return of Capital. Put atick (./)
"!1ft ~ <I T 3I tR fi't<I ;(;q <t'l tffiG q;'r <:Wl1
I f yes, indicate your choice of alternative
~ /Yes "'lift /No
CJ CJ
[!][2J w
11. #'i'l\'\ <t'l "Cf"T tffit~ "fIfim mfctff "CI >T ~ ~ cmI
Mention your Nominee for Return of Capital
~/ Name
ml Relation
'lOl/ Address
I I I I I I I I
w<I ~/Date of Birth) (dd/mmlyyyy)
#~ 26.09.2008 lI T ~ ~ "" tm;r ~ Wr.1t fit; ~ "if ~ ~/Not applicable if pension start date is on or after 26-09-2008.
12. ~ <P T f<tcRuT / Particulars of Family
~. <to ~ \iI""1~/~ ~ <p~'#li~
~ et; ~ <:Wl/lndicate against Minor
SI .No. Name Date of Relationship with Member
Birth/Age
~<P T ~ ~et;"Wl"m
Guardian Name Relationship with Member
(1) (2) (3) (4) (5) (6)
~ :~ ~ iltt.rr ~ ~ tf fc/q;ffi7r ~ <I T "fT 1{ et; ~ 'arn<ffi' GWlI
Note: I f any child is physically handicapped, please indicate "DI SABLED" below his/her name.
13. ~ <t'l ~ <t'l ~ ~ ~ m) I Date of death of Member (ifapplicable)
1 1 I I I I I I I
14 ~ ~ ~ ffi' <P T f<tcRuT /Details of Bank Accounts Opened
1 ~ <P T "fT 1{/ Name of the Bank
mm <P T "fT 1{ I Name ofthe Branch
2
3 'l'l 6ICfi l:jffi'1 Full Postal Address
~ q;);s I Pin Code
(~~ - am ~ ~/~ 'tII;iIt 1llI!' lIftt~ eR Please attach a copy of cancelled/blank Cheque)
#~/~ rf; ~/ Signature of member/applicant f./tiI 1mr ci; ~/ Signature of Employer
Form I OD (www.epfindia.gov.in) Page 2 of6
'fi. ~. ~/~1'ffl"'Wf/ "ifim. tq; - mm ~. /
SI No Name ofClaimant(s) Saving Bank Account Number
14. .A (c!i) ~ GT <I T fcI rn\ "'I lf>rff <Z I fcltr "[RT ~ fclx rr 7J <I T ~ m~ ~
(a) I f the claim is preferred by nominee, indicate hislher.-- ---...,
(1) 'Wf/ Name IL.. ., - - \
(2) ~ ~ ct; ~ ~/ Relationship with deceased Member
15. ~ Wll"f 1'ffl"flm"ur ~ Cffl ~ tr
~ ct; tjffi m ~ cfflt m}
Detail of Scheme Certificate already in
Possession of the Member, ifany
~ ~ m'<f ~ "fiofr.f fclx rr I
Scheme Certificate received &enclosed
m'<f -;ffi) / Not received
D
D
D
"ffil!~ Not Applicable
~"SI T '<! t en ~/ifReceived, I ndicate:
~.
Scheme Certificate Control No
'fi. ~.
SI No Authority who issued the Scheme Certificate
16. ~ ~ q;. if. m., 1995 ct; 3Rf1fQ ~ \iI T 1(jft ~
I fpension is being drawn under E.P.S, 1995
l\l.l\l.31T :if.
PPONo
et. rvr. / \3'. et. <!iT . "[RT -;;ffi)
I ssued by RO/SRO
17. ~ ~ (~et; ~ ~/ Documents enclosed (I ndicate as per the I nstructions)
1.- - - - - - - - - - - - -
4. _
2. _ 5. _
3. _ 6. _
~ fiI mr vmrr ~I Certified that;
0) i'f ~ mmwrr, 1995 et; ~ iWf ;ffil ~ W tl
I amnot drawing Pension under Employee's Pension Scheme, 1995.
Q i) ~ ~ tf?[ "4 ~ flm"ur ~ ~ -mt t I
T he particulars given inthis application are true and correct
~lDate
~lPlace ~ et; ~ <rn 6W <t'I 3t'!,OT f.mJ;ft
Signature I Left Hand T humb I mpression ofthe applicant
~ ~ ~/SigDature of Employer ~ .
f.\1I )1ft!y/~ ~ um 'Rf 'GI Rrt)
Form I OD(www.epfindia.gov.in) Page 3 of6
(T O BE FI LLED UP BY T HE EMPLOYER!
AUT HORI SED OFFI CER OF T HE EST ABLI SHMENT )
lI J !I fiI Rr Fcmrr \lJ J ill ~ ~ / Certified that:
1. ~<I iT ~mlHI
T heparticulars of themember arecorrect.
2. ~ ~ q\\ ~ ~ ~ ~ 12 ~ q\\ ~ <liT ~ ~ iWt ~ <liT ~ I
T heparticulars of Wages and Pension Contribution for theperiod of 12 months preceding the dateofleaving service are
as under:
~ ~ wfi 12 ~ T j ~ ~ <Cl 'I t ~ m 12 'I lft;I T ifj[ ~ -31f.<rq"ill< ~ ~ ~ J lNI 'l{ ~
(in case, thewages arenot earned for all 12 months, theblock of 12 months will commence backwards fromthelast pay
drawn)
<i't ~ ~/ Wages
~1llA~ "" ai"mT I lt ~ <I >ltffiuT I mG ..~
Year Month Pension ~~~tm~GW'f
contribution due Details of period of non- contributory
service. I f there isno such period,
indicate 'Nil'
~q\'t<'i. ww "lfIf/ Year ~q\'\<'i.~~~
No. of days Amount
~ 3lAAcr ~ q\\
'I t/ no. of days for
which nowages were
earned
(1) (2) (a) (4) (5) (6) (7)
~ : Enclosures:
I .~ -q ~ ~/ Docurnente asgiven intheI nstruction
2.~q~uilCi1q>~ ~ ""flT ~ ifj[ "I f'BI /Formof descriptive roll and specimen signature
~lDate
~fplace
~i!\"~/~~
"$ ~ ~ ~ *ft'IIIIN
Signature of Employer! Authorised Official
of the Establishment with Seal and Date
Form I OD(www.epfindia.gov.in) Page 4of6
~~1ffiI ~~<f;~"'I ~ 2 ~"'I lffi1O~\iI l\[)
(T o be submitted in duplicated in respect of each person eligible for pension)
~ -M't <fiT fc'fcRur aI R ~ ~ ~/~ f.rnT 'l
Descriptive roll of Pensioner and his/her Specimen SignaturefT humb impression
l.~ <fiT "'frI {/Name of the Member
2.lI >.'l'f.f.'t. ~ <'i./E.P.F Account Number
3.m 1Wft<fiT "'frI {/Name of the Pensioner
4.furr/l!fa <fiT "'frI {/Father'slHusband's Name
5.fwT / Sex
6.~/Nationality
7.q4/ Religion
8 :wmV Height
1 .
Personal Marks ofldentification 2 .
Specimen signature of pensioner 1 .........................................................
2 .
3 .
I I .~ f.Rffi" ~ ~ -M't) ~ qlt cmr 1{ ;ml ~ qlt ~ <f; f.rnT 'l.
[Only in the case of illiterate Claimant (Pensioner) Left Hand Finger I mpression]
~/THUMB ~/INDEX "It2PIT1MI DDLE ~/RING
q;f.rerl SMALL
~/ Place:
~/Date:
~/ Signature
~~<f;"'frI {~>I T iR
Name of the Attesting Authority Official Seal
Fonn 100 (www.epfindia.gov.in) Page 5of6
~~~~)
(FOR OFFI CE USE ONLY)
(tl'wi 3Fj"1I 'T /mm 3Fj"1I 'T )
(pENSI ON SECT I ON/ACCOUNT S SECT I ON)
WlT flI RI ~ iiI mT ~ ~ ~ ~ T j ~ ~ <!iT ~ ~ ~ ~ WI fCI "'f <I R fRm 7fm t 1 ~ ~ tg'lBI t 1 3lJ qif; ~ ~
~~~)- ;jh)~~tl
Certified that theparticulars intheapplication have been verified with the relevant concerned documents, the claimant iseligible for
Pension. T he I nput Data Sheet isplaced below for approval:
~-9/lI 1rn-3 ("4. tft.) 'ffiC< mm ~/GT Q I 3lJ qif; ~ ~ ~ <I R <'ft ~ tl
Entered inForm91F0rm3(PS). Master Ledger Card! ClaimI nward Register
~&m~~~~~-2 (3lRl~tl
Form2( R) enclosed along with the documents furnished by theClaimant.
'ffi.~.~./ S.S.A. 3lj. ~/ S.S. ~.~. ~./ A.O. ~.'f.f.J .arrg(/tffi)/ A.P.F.C.(Pension)
~/Date ~/Date ~I Date ~I Date
~"ff'!"lmsn~<t;~
(FOR USE I N PENSI ON PRE-AUDI T CELL)
~ srer ~ ~ ~ ~ ~ ~ ~ <I f.!I ~ <I R ~ 'lm ~ am-mT tJ r!lT 7fm t1 ti. 3RWft 3l$T q;'t ~ &m "1hrn
<I R~V!T 1;[1
T heI nput datesheet verified with reference tothe application and the documents enclosed and found correct. P.P.O may be
generated through Computer.
'ffi.~.~./SSA 3lj. ~/S.S ,b~./A.o. ~.'f.f.!t.arrg~)/ A.P.F.C.(Pension)
~/Date ~/Date ~/Date ~/Date
(/tffi flI <Rur ~ ~ ~)
(FOR USE I N PENSI ON DI SBURSEMENT SECT I ON)
T t 31. 31. "fi.
P.P.O.NO.
ltcI; lI i't U JRt <I R'l ctft ~
Dateof issueto theBank
ta>
Bank
~ lI i't ~ <f1!I T mm 3!'J 'WT q;'t ~ U JRt <I R tt ~ ~1
I ntimation sent to the Claimant and also to Account Branch on
'ffi.~.~./ S.S.A. 3lj. ~/ S.S.
~.~./ A.O. ~.'f.f.!t.arrg~)/ A.P.F.C.(Pension)
~/Date ~/Date ~/Date ~/Date
Form I OD(www.epflndia.gov.ln) Page 6of6