Form 10c

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) Father’s Name

_____________________________

b) Husband’s 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)