FORM No. 10 - C (E.P.S.

)
EMPLOYEE'S PENSION SCHEME - 1995
Inward No:

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME 1995 FOR

CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Read the instruction before filling of this form)

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 and address of the Establishment

in which, the member was last employed

5 Code No. & Account No. RO/SRO Code

Estt Code No. A/c No.

6 Reasons for leaving Services Resigned

& Date of Leaving

7 Full Postal Address (in Block Letters)

Sri / Smt. / Kum.
S/o. / D/o. / H/o. / W/o.

PIN :

8 Are you willing to accept Scheme (a) Yes (b) No

Certificate in lieu of Withdrawal Benefits ?

9 Particulars of Family(Spouse,children or Nominee

Name Date of Birth Relationship Name of the
with the member guardian of minor
(a) Family member/(s)
 (b) Nominee

10 Incase of death of the member after the age of 58 years without filing the claim :

(a) Date of death of the member

(b) Name of the claimant(s) and

relationship with the member

11 MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ON OPTED)

(a)By postal money order at my cost to

the address given against column No.7

(b) Account payee cheque sent direct for

credit to my S.B.A/c (scheduled bank)
under Intimation to me.

S.B A/C No

ECS Code No.

Name of the bank(in block letters)

Branch(in block letters)

Full postal address of the Branch

(in block letters)

PIN

12 Are you availing pension under EPS-1995 if so,indicate

PPO No by whom issued

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

Date Signature/Left hand thumb impression of the Member/cliamant(s)

ADVANCED STAMPED RECEIPT
(To be furnished only in case of 11(b) above)

Received a sum of Rs _____________________ (Rupees______________________________________ only)

from the Regional PF Commissioner/officer-in-Charge of Sub-regional Office, by depositing in savings Bank A/c
towards the settlement of my Pension Fund account.

The space should be left blank which shall be filled by this office. Affix Rs 1
Revenue
stamp
Signature/left hand thumb impression of the member on the
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 furnished under
(Form 3A/7(EPS) enclosed for the period for which was not sent to Employees' Provident Fund Office).

Date of joining

Wages (Basic+D.A) as on 15/11/95

(if applicable)

Wages on the date of exit

Y M D

Period of non-contributory service

Date Signature of Employer/Authorised Offical with Rubber stamp

(FOR THE USE IN OF COMMISSIONER'S OFFICE

(Under Rs ____________________________ P.I. No_____________________ M.O/cheque __________________

passed for payment for Rs_____________ (Rupees_____________________________________________ only)

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

D.A S.S A.AO

(FOR USE IN CASH SECTION)

Paid by inclusion in cheque no_______________________________date _______________vide Cash Book

Account no.10 Debit Item No. __________________

D.A S .S AC(Cash)

For Issue of S.S. ; IDS is enclosed.

D.A S.S APFC(A/cs)

( FOR USE IN PENSION SECTION)

Scheme Certificate bearing the control no issued

issued on and entered in the
Scheme Certificate Control Register.

D.A S.S APFC(Pension)