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9611786747961178674796117867479611786747 Serial No. For Office Use Only In Words No.

Serial No.

For Office Use Only

In Words No.

FormFormFormForm No.10No.10No.10No.10 CCCC (E.P.S)(E.P.S)(E.P.S)(E.P.S) [Withdrawl[Withdrawl[Withdrawl[Withdrawl Benefit]Benefit]Benefit]Benefit]

EMPLOYEES'EMPLOYEES'EMPLOYEES'EMPLOYEES' PENSIONPENSIONPENSIONPENSION SCHEME,SCHEME,SCHEME,SCHEME, 1995199519951995

FORMFORMFORMFORM TOTOTOTO BEBEBEBE USEDUSEDUSEDUSED BYBYBYBY AAAA MEMBERMEMBERMEMBERMEMBER OFOFOFOF THETHETHETHE EMPLOYEES'EMPLOYEES'EMPLOYEES'EMPLOYEES' PENSIONPENSIONPENSIONPENSION SCHEME,1995SCHEME,1995SCHEME,1995SCHEME,1995 FORFORFORFOR CLAIMINGCLAIMINGCLAIMINGCLAIMING WITHDRAWLWITHDRAWLWITHDRAWLWITHDRAWL BENEFITBENEFITBENEFITBENEFIT //// SCHEMESCHEMESCHEMESCHEME CERTIFICATECERTIFICATECERTIFICATECERTIFICATE

1.

a) Name of the member (In Block Letters)

b) Name of the Claimant (s)

2.

Date of Birth

3.

a)

'

Father's Name

b)

Husband's Name (If applicable)

4.

Name & Address of the Establishment

in which, the member was last employed

5.

Code No. & Account No.

6.

Reason for leaving service

& Date of leaving

7.

Full Postal Address (In Block Letters)

Shri/Smt/Kumari

S/o, W/o, D/o

KarunakaranKarunakaranKarunakaranKarunakaran YYYY NNNN

2222 4444 NarayanaNarayanaNarayanaNarayana YYYY
2222
4444
NarayanaNarayanaNarayanaNarayana YYYY
1111 1111
1111 1111
8888 0000
8888 0000

NOTNOTNOTNOT APPLICABLEAPPLICABLEAPPLICABLEAPPLICABLE

Region/SRO Code / Estt.Code No. A/c No.
Region/SRO Code
/
Estt.Code No.
A/c No.
Region/SRO Code / Estt.Code No. A/c No. PersonalPersonalPersonalPersonal

PersonalPersonalPersonalPersonal ProblemProblemProblemProblem

ProblemProblemProblemProblem 1-Feb-20121-Feb-20121-Feb-20121-Feb-2012

1-Feb-20121-Feb-20121-Feb-20121-Feb-2012

KarunakaranKarunakaranKarunakaranKarunakaran YYYY NNNN

NarayanaNarayanaNarayanaNarayana YYYY

#### 12,12,12,12, ABCABCABCABC [Vill],[Vill],[Vill],[Vill], BSSSBSSSBSSSBSSS [Po][Po][Po][Po] UUIIIUUIIIUUIIIUUIII [Mandal][Mandal][Mandal][Mandal]

KuppamKuppamKuppamKuppam [Tq][Tq][Tq][Tq] ChittoorChittoorChittoorChittoor Dist,Dist,Dist,Dist, AndhrapradeshAndhrapradeshAndhrapradeshAndhrapradesh ---- 517423517423517423517423

8. Are you willing to accept Scheme

Certificate in lieu of withdrawl benefits

Yes

(a) (b) No √
(a)
(b)
No

9. Particulars of Family (Spouse & Children & Nominee)

Name

Date of Birth

Relationship with member

Name of guardian of minor

(a) Family Members

NarayanaNarayanaNarayanaNarayana

03-05-195603-05-195603-05-195603-05-1956

FATHERFATHERFATHERFATHER

----

SaraswathiSaraswathiSaraswathiSaraswathi

14-05-196014-05-196014-05-196014-05-1960

MOTHERMOTHERMOTHERMOTHER

----

(b)

Nominee

LavanyaLavanyaLavanyaLavanya GGGG

22-22-198022-22-198022-22-198022-22-1980

WifeWifeWifeWife

----

PankajPankajPankajPankaj YYYY

20-02-20120-02-20120-02-20120-02-201

SonSonSonSon

----

10. In case of death of member after attaining the age of 58 years without filing the claim :-

(a)

Date of death of the member

::::

NotNotNotNot ApplicableApplicableApplicableApplicable

(b)

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

NotNotNotNot ApplicableApplicableApplicableApplicable

11. MODE FOR REMITTANCE [PUT A TICK IN THE BOX AGAINST THE ONE OPTED]

(a)

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

(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 Account No.

6400000000000640000000000064000000000006400000000000

√

Name of the Bank (In Block Letters)

STATESTATESTATESTATE BANKBANKBANKBANK OFOFOFOF MYSOREMYSOREMYSOREMYSORE

Branch (In Block Letters)

BANASWADIBANASWADIBANASWADIBANASWADI

Full Address of the Bank

KRKRKRKR ROAD,ROAD,ROAD,ROAD,

(In Block Letters)

BANGALOREBANGALOREBANGALOREBANGALORE ---- 24242424

12. Are you availing pension under EPS-95?

::::

NoNoNoNo

If so indicate:

PPO No.

By whom issued

CertifiedCertifiedCertifiedCertified THATTHATTHATTHAT THETHETHETHE PARTICULARSPARTICULARSPARTICULARSPARTICULARS AREAREAREARE TRUETRUETRUETRUE TOTOTOTO THETHETHETHE BESTBESTBESTBEST OFOFOFOF MYMYMYMY KNOWLEDGEKNOWLEDGEKNOWLEDGEKNOWLEDGE

D

0202 0404 20122012

Signature or left Hand

Thumb Impression of the

M

b

Cl

i

ADVANCEADVANCEADVANCEADVANCE STAMPEDSTAMPEDSTAMPEDSTAMPED RECEIPTRECEIPTRECEIPTRECEIPT [To be furnished only in case of (b) above]

Received a sum of Rs

only from the 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

(Rupees

(The space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer-in- charge)

Signature or left 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

e ore 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 Employee's Provident Fund Office)

Wages (Basic+DA) as on 15.11.1995 (if applicable) ::::

Wages as on the date of exit

::::

PeriodPeriodPeriodPeriod ofofofof nonnonnonnon contributorycontributorycontributorycontributory ServiceServiceServiceService

Year / Month

No. of Days

TOTALTOTALTOTALTOTAL

0.00.00.00.0

Date:

Signature of Employer/

authorised official

(FOR(FOR(FOR(FOR THETHETHETHE USEUSEUSEUSE OFOFOFOF COMMISSIONER'SCOMMISSIONER'SCOMMISSIONER'SCOMMISSIONER'S OFFICE)OFFICE)OFFICE)OFFICE)

(Under Rs

P.I No

M.O./Cheque

Passed for payment Rs M.O Commission (if any)

Net amount to be paid by M.O

towards withdrawl benefit.

D.HD.HD.HD.H

S.SS.SS.SS.S

(in words)

A.A.OA.A.OA.A.OA.A.O

Paid by inclusion in cheque No No. 10 Debit item No

(FOR(FOR(FOR(FOR USEUSEUSEUSE ININININ CASHCASHCASHCASH SECTION)SECTION)SECTION)SECTION)

Dt

vide

cash Book(Bank) Account

D.HD.HD.HD.H

S.SS.SS.SS.S

AC(A/cs)AC(A/cs)AC(A/cs)AC(A/cs)

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

D.HD.HD.HD.H

S.SS.SS.SS.S

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

(FOR(FOR(FOR(FOR USEUSEUSEUSE ININININ PENSIONPENSIONPENSIONPENSION SECTION)SECTION)SECTION)SECTION)

Scheme Certificate bearing the Control No entered in the Scheme Certificate Control Register-

Issued on

and

D.HD.HD.HD.H

S.SS.SS.SS.S

A.A.OA.A.OA.A.OA.A.O

 

APFCAPFCAPFCAPFC (PENSION)(PENSION)(PENSION)(PENSION)