Form 10c

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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)
Branch
(in block letters)
Full Address Of the Branch
(in block letters)

______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

12.

Are your availing pension under EPS-95 ?
If so indicate

:

PPO NO._________________By Whom Issued______________

Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE Signature or left Hand
Thumb Impression of the
Member / claimant(s)
Date ______________

ADVANCE STAMPED RECEIPT
[To be furnished only in case of (b) above]
Received a sum of Rs…………….(Rupees……………………………………………………………………….) Only from 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. (The Space should be left blank which shall be filled by Regional Provident Fund Commissioner /Officer-incharge)

Signature & left hand 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.

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 + D.A) as on 15.11.95(if applicable)

Wages as on the date of exit
Period of non contributory Service
Year/Month
No.of days

Date………………………

Signature of Employer/
authorised Official

(FOR THE USE OF COMMISSIONER’S OFFICE)

(Under Rs…………………………………………………………………………………………………………………… P.I. No ……………………………………………………M.O./Cheque

Passed for payment for Rs. …………………………………(in words)………………….. ………………………………………………………………………………………………………………………………. M.O. Commission (if any)……………………………net amount to be paid by M.O………………………………… towards...
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