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    10c

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    Mohammad Ishaq
    10

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    © All Rights Reserved
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    10c

    Uploaded by

    Mohammad Ishaq
    22 views4 pages
    10

    Original Title

    Copy of 10c

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    10

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    22 views4 pages

    10c

    Uploaded by

    Mohammad Ishaq
    10

    Copyright:

    © All Rights Reserved
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    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 BENEFIT/SCHEME CERTIFICATE
    (Read the instructions before filling up this form)

    1.

    a) Name of the member :( In Block Letters)


    b) Name of the claimant (s)

    _____________________________
    _____________________________

    2.

    Date Of Birth

    3.

    a) Fathers Name

    _____________________________

    b) Husbands Name
    (If applicable)

    _____________________________

    4.
    5.

    Name & Address of the Establishment


    in which, the member was last employed

    ______________________________

    Code No. & Account No.

    Region/SRO Code
    Estt. Code No.

    6.

    Reason for leaving service


    & Date of leaving

    A/c No.

    ______________________________
    ______________________________

    7.

    Full Postal Address :(In Block Letters)


    ___________________________________
    Sh/Smt./Km
    ___________________________________
    S/o, W/o, D/o
    ___________________________________
    ___________________PIN_____________

    8.

    Are you willing to accept Scheme

    (a)

    Certificate in lieu of withdrawal benefits


    9.

    (b)

    Yes

    No

    Particulars of Family (Spouse & Children & Nominee)

    Name

    Date of Birth

    Relationship With Member

    Name of the guardan of minor

    (a)

    Family
    Members

    (b)

    Nominee

    10.

    In case of death of member after attaining the age of 58 years without filing the claim:(a)
    (b)

    11.

    Date of death of the member :


    Name of the Claimant(s) / and relationship with the members :

    MODE FOR REMITTANCE [PUT A TIC IN THE BOX AGAINST THE ONE OPTED]
    (a)

    By postal money order at my cost to address given against item No. 7

    (b)

    Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation
    to me

    S.B. Accounts No.

    ______________________________________________

    Name of the Bank


    (in block letters)
    Branch
    (in block letters)
    Full Address Of the Branch
    (in block letters)

    ______________________________________________
    ______________________________________________
    ______________________________________________
    ______________________________________________
    ______________________________________________

    12.

    Are your availing pension under EPS-95 ?


    If so indicate

    PPO NO._________________By Whom Issued______________

    Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE


    Signature or left Hand
    Thumb Impression of the
    Member / claimant(s)
    Date ______________

    ADVANCE STAMPED RECEIPT


    [To be furnished only in case of (b) above]
    Received a sum of Rs.(Rupees.)
    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 filled by Regional Provident Fund Commissioner /Officer-incharge)

    Signature & left hand thumb impression of the member on the stamp

    Rs 1/Revenue
    Stamp

    Certified that the particulars of the member given are correct and the member has signed/thumb 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 employees Provident Fund Office)

    Wages (Basic + D.A) as on 15.11.95(if applicable)

    Wages as on the date of exit


    Period of non contributory Service
    Year/Month
    No.of days

    Date

    Signature of Employer/
    authorised Official

    (FOR THE USE OF COMMISSIONERS OFFICE)

    (Under Rs
    P.I. No M.O./Cheque

    Passed for payment for Rs. (in words)..


    .
    M.O. Commission (if any)net amount to be paid by M.O
    towards withdrawal benefit.

    D.H.

    S.S

    A.A.O

    (FOR USE IN CASH SECTION)

    Paid by inclusion in cheque NoDt..vide cash Book(Bank) Account


    No. 10 Debit item No.

    D.H

    S.S

    AC(A/cs)

    S.S

    A.A.O/APFC(A/cs)

    For issue if S.S;. IDS is enclosed.

    D.H

    (FOR USE IN PENSION SECTION)


    Scheme Certificate bearing the control No..Issued on ..and
    entered in the scheme Certificate Control Register-

    D.H

    S.S

    A.A.O

    APFC(PENSION)

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