This document is a form for claiming withdrawal benefits or a scheme certificate from the Employees' Pension Scheme 1995. It requests information such as the claimant's name and address, date of birth, father/husband's name, last place of employment, account details, reason for and date of leaving service, family/nominee details, preferred mode of payment, and certification of employment details. The claimant must provide signatures or thumb impressions to verify the information and claim benefits from the pension scheme.
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This document is a form for claiming withdrawal benefits or a scheme certificate from the Employees' Pension Scheme 1995. It requests information such as the claimant's name and address, date of birth, father/husband's name, last place of employment, account details, reason for and date of leaving service, family/nominee details, preferred mode of payment, and certification of employment details. The claimant must provide signatures or thumb impressions to verify the information and claim benefits from the pension scheme.
This document is a form for claiming withdrawal benefits or a scheme certificate from the Employees' Pension Scheme 1995. It requests information such as the claimant's name and address, date of birth, father/husband's name, last place of employment, account details, reason for and date of leaving service, family/nominee details, preferred mode of payment, and certification of employment details. The claimant must provide signatures or thumb impressions to verify the information and claim benefits from the pension scheme.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as XLS, PDF, TXT or read online from Scribd
This document is a form for claiming withdrawal benefits or a scheme certificate from the Employees' Pension Scheme 1995. It requests information such as the claimant's name and address, date of birth, father/husband's name, last place of employment, account details, reason for and date of leaving service, family/nominee details, preferred mode of payment, and certification of employment details. The claimant must provide signatures or thumb impressions to verify the information and claim benefits from the pension scheme.
Copyright:
Attribution Non-Commercial (BY-NC)
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Download as XLS, PDF, TXT or read online from Scribd
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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
