1234567890

Mobile Number

TCS Employee ID 123456

EMPLOYEES PROVIDENT FUNDS ORGANIZATION

COMPOSITE CLAIM FORM
FORM NO - 10C (PENSION WITHDRAWAL BENEFITS)

Claim Applied for: Pension Withdrawal Benefits

1 Update your TCS
pension number, which
2 Name of the Member : (IN CAPITAL LETTERS) NARENDRA YADGIRI SAMUDRALA
is available on PF
a): Universal Account Number (UAN) a): 123456789012 statement.
3
b): Pension Number (EPS). (In case UAN is not available). b): MH/BAN/48475/123456
4 Aadhaar Number (for seeding) : 123456789012
a): Fathers name: Mr Yadgiri Samudrala
5
b): Husbands name: N/A
6 Date of Birth: 17th Nov 1986
7 Date of Joining Establishment: 14th Aug 2006
8 Date of Leaving Service : 20th March 2017
a): Permanent Account Number.(PAN):
ABCDE1234K
9 b): Reason for Leaving Service:

- Service Terminated on account of

(a) ill health of member

(b) Contraction / Discontinuation of employers business or
(c) Other Cause beyond the control of the member

- Personal Reasons.
Resignation.
10 Bank Account Details for Payment: Saving Bank Account Number.
123456789012
(Please attach a copy of cancelled cheque/attested copy of .
first page of passbook) Name & Address of the Bank. Citibank NA ,

Fort, Mumbai PIN: 400093

IFS Code : CITI100001

11 Full Postal address 123/B- Pride CHS, Near Hyper city Mall, G.B Road,
Thane West.

Pin 400615.

- The member herby declares that he has not been employed for two months (Yes/No)
- Certified that the particulars are true to the best of my knowledge.

Members Signature
Employers Signature
Designation & Seal of Employer
Guidelines for filling Composite Claim form.

The Total Service in the present establishment as well as previous establishment is counted and, therefore, it is advisable
to merge all PF accounts.
Pension withdrawal benefits can be availed only if the service is less than 10 years.
A cancelled cheque containing the name of employee, Bank A/c number and IFS Code is attached with the claimed form.