~~.

Mobile Number
~ ~ ~ ~/ For Office Use Only

'I;TIU ~/Clam

I.D

mlt ~ MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRlBUTING PERIOD 1. (q;)
<I>T "'W! ~ ~ ~/ <I>T"'W! Name of the claimant (s):

lmr 10 ~ FORM lOC FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE ~ ~ ~, 1995 EMPLOYEES' PENSION SCHEME, 1995 lmr ~ ~ ~ ~ q;l W/(Read the instructions before filing up this form) 180 ~ (i\i ~ _liS) U\i ~, i "'" ~i lit ~ W'J '& ~ t I WITIIDRA WAL BENEFIT IS NOT ADMISSIBLE
$1'11014'51 ~ ~ fimTr \iJA Cffiffi
Name of the Member (In Block letters):

I~

tu ~

IF

_ _

~) GNm

2.

~/Date

of Birth

(dd/mm/yyyy)

3.

1ilor<liT "'I1'I/Father's Name

qfff <I>T"l[l{ Husband's Name (If applicable) _

Name & Address of the Establishment in which,

5.

the member was last ~ <t. om ~ <t.

employed

W-;r/ <I>T m
Region/Off Code

~qft~<t. Estt. Code No.

~<t.
A/c No.

Code No. & Account No.

~~~~I
SA) ~ ~/Date <I>T Cffl<U[ of Joining the Estt.

I~

~I~I

~
_

6.

mu ~

om

mr~CIlt~
Reason for leaving service & Date of leaving 7.

'!'T

'fflT ~

areffl ~
_ _ W/o, D/o.

Full Address (In Block letters) ~/~/~/Sh./Smt./Km. ~/'I<'ft/~/S/o,

'fflT/

Adress
flR/PIN

_
_

_________________________

#~

~~

3JeICIT <mt/<:TI:t ~

~ ~

<I>T f.mR

# f.r<irqffi ~ ~

/Employer' s Signature

Signature or left / Right hand thumb impression of the member

Form IOC (www.epfindia.gov.in )

Page

1of4

8.

l!lll

anq ~

W'fI1ITtI?I ~

~ -$ <eWr 1R ~ "IIR't -$ ~ ~ I

tiT Yes

;;ift NoO

Are you willing to accept Scheme Certificate in lieu of withdrawal benefits lIff: ~ 180 ft'f (fk ~ ~ "'" ~ lI'R). 'W ~ ~ t """ ~ <!Il'f ;\-q- ~ tI Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service. 9.
tftc!R <m~ (qftI/""*

owr ~
~

(!IqT ~)
~ ~ / applicable only for Scheme Certificate option)

Particulars of Family (Spouse & Children & Nominee)

(~
(q (a)
~tt;~

wnur

1f3f ~

"'lTl! Name Family members

\iJri'I~

Date of Birth

~tt;Wi"&oiw Relationship with Member

~tt;~<m"'lTl! Name of the guardian of minor

<) (b) 10. (q <) 11. (q ta)

~ Nomine ~ ~ ~ ~ ~ ~ ~ ~
58 "<I"'f ~ ~ "SlT'<I "IIR't -$ iITG ~ ~ ~ ~
lR. :-

In case of death of members after attaining the age of 58 years without filling the claim:q\1 ~ / Date of death of the member "&oiw/Nameof the Claminant(s)/and ~
-$ 3Ij<lR
~

-$ "'lTl!/(!IqT ~,,~ q;r ~ ~

relationship with the member

Cf>ltcq;"iitm

Mode of remittance (put a tick in the box against the one opted) 'IG "ff. 7 " ~ q<f lR ~ <Wf(f lR Wf> ~ QRT Bypostal money order at my cost to the address given against item No.7: ~ ~ <mrr "'.(~ ~/~) it ~ ~/ ~ ~"fl3llmOT <mrr ~ >lvrr vm;/ (b) Byaccount payees chequel electronic mode sent Directly for credit to my 5.B. Alc (Scheduled Bank IP.D.) under intimation to me.

m~~~

iffi'f ~

<mrr ~/S.B. Account No.

3!1ffXT "ii/Name

~ q;r"'lTl!~
~ ~ 3!ffiT

of the Bank (In Block letters)

1'i)/Branch (In Block letters) IFSCode

3!ffiT

anl.~.~ .. m/
~
(~

q;r '!<T lRIT~

tq; ~

1'i)/Fulladdress of the Branch

"C!lIi lIftr~

(In

Block Letters) : Cheque)

-$ ~/~

tct; i!I't

Please attach a copy of cancelled/blank

12.

~ anq q;.q. <fr. 95 ~ <mY ~ ~ q;'{ ~ t ? Are you availing pension under EP5-95 ? ~ tiT. 0) ~ i!R If yes, indicate 1\\.1\\.* . .t. PPD No .
~ ~

m/Yes
~QRT~

;;ift/No

D
.

Bywhom issued
~/

fcmrr

\jffiff ~ ~

filcRuT ~

WfA ~

Certified that the particulars are true to the best of my

knowledge

~/~

-$ ~

;mt m ~ a'f'lP

<mf.MR

Form lOC (www.epfindia.gov.in )

Page 2of4

~
Date .

Signature or left Hand Thumb impression of the Member/Claimant

#~
3lfWI~~

~ ~

/Employer's

Signature

Advance Stamped Receipt <f; ~ Tt ~ lI<W' ~ ~) [To be furnished only in case of (b) above)
~ i3itR ~)

tw.f AA mtr ~ f.ItrGR "ffiii'! ~ ~ f.rft ~ /\J!l"~ ~ <f; ~ ~ ~ ~ <r<rntq; mtr Ti ;jf'lf Gm ~ ~ -q) ) ~ <rfu"llJ'([ ~ I Received a sum of ~ (Rupees ) only from Regional Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office by deposit in my savings Bank Alc towards the settlement of my Pension Fund Account. i/tlfi ~ fuI ~ ~ q;)- ~ ~ f.rft ~/:II'ffit ~ Gm 1ffi ~ I

The space should be left Commissioner/Officer-in-charge)

blank

which

shall

be

filled

by

Regional

Provident

Fund

f 1 Revenue ~ 'R ~
<f; ~

3l'R <i'tll ~

<f;

ai <lIT f.mR

Stamp

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

fcI;<rr "ijffffi t fll; ~

Gm fuI fclcRuT

"ffift

t 3l'R~

-q ~ ~

~ /~

f.mA'r wnt

tI

Certified that the particulars of the member given are correct and the member has signedlthumb impressed before me. ~~~~~~~cj;~~t:The details of wages and period of non-contributory service of the member are as under: (Jmr-3~/7) (cP.t1:lJt.) ~ ~ <f)[ ~ t ftrn ~ ~ ~ ~ ~ AA ~ q;'r~ 1iff lJ1;1 e)"1) (Form 3A17 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund Office)
~ 15.11.95 q;'r~ ("'!<'! ~ +~ 1fffi) ~ <'IT'!. t) Wages (Basic +D.A.) as on 15.11.95 (if applicable) ~~<Cr~q;'r~

Wages as on the date of exit iRamGPft~~

CI'f/"I!ffi

~:

Period of non contributory Service :

~
No. of days
f.'ImcffiT/~ ~ <f; ~

Year/Month

~
Date .
~ ~ <f; ~ <f; ~/~

Signature of Employer/Authorised (For the use of commissioner's office)

'IG

Official

f
Under f ~ Passed for payment forf ~ ~ <6'Ii t) M.O.Commission (if any) benefit. ~i!

.t

>r-fi~/-;1Jq;

P.I.No

M.O.lCheque. ~~~~fcl;<rrl . ~ ~ ~

(in words)

f.rcwr

<rfu

. towards withdrawal

net amount to be paid by M.O

Form lOC (www.epfindia.gov.in

Page 30f4

m.~."ff.

~
5.5.

R~.3lft).

SSA

A.AO.

(~~~) (For use in Cash Section) ~"fi

"ff.-l0 ~

~
llG ~
1R ~ ~

imTm~~~~)wm

fc;tm t I
Dt vide Cash Book (Bank) Account No.10 Debt

Paid by inclusion in cheque No item No

313

ml.

~. ~.

Iq;G)

S.S
"!RI. "!RI.. ~ ~ ~ ~ ~.

AC (Cash)

"tl. ~ "fiorr.I

t :-

For issue of S.C., IDS is enclosed

"W.~."ff.

3lj. tfl\.

R~.3lT.

~.'l.f.'r.3lT. ~)

SSA.

S.S.

A.AO.

APFC (Alcs.)

~~~~
(For use in Pension Section)
"1ll\iRT ~

lm! 1R ~

"ff

t. <it ~

.................................................................... <it ~

aft< ~

Wl]"t1JtR

f.I<Rur Q\;ft if qft I issued on and

Scheme Certificate bearing the control No entered in the Scheme Certificate Control Register.

3lj. tfl\.

~.'l.f.'r.3lT. ~)

SSA

s.s.

AAo.

APFC (Ncs.)

Form IOC(www.epfindia.gov.in )

Page 40f 4