Serial No: For Office Use Only In Words No. Form No. 10 C(EP.S) EMPLOYEES' PENSION SCHEME, 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE instr a) Name of the member :- (In Block Letters) by Name of the claimant (s) Date OF Birth a) Father's Name b) Husband's Name (applicable) Name & Address of the Establishment in which, the member was last employed Code No. & Account No. Reason for leaving service & Date of leaving Full Postal Address (In Block Letters) ShiSmtskm Slo, Wio, Dio HAL C&mevs EAT (LwozA) RegloniSRO Codd Estt. Code No. Alc No. DOB cH E 20/06) 20\1W PVT. LT),& Are you willing to accept Scheme @) (b) Certificate in lieu of withdrawal benefits Yes No| 9. Particulars of Family (Spouse & Children & Nominee) Name Date of Birth Relationship With Member Name of the guardan of minor @) Family VALS HALT WEEE Members (e) Nominee 10. Incase of death of member after attaining the age of 58 years without fling the claim:- (a) Date of death of the member () Name of the Claimants) / and relationship with the members : 11, MODE FOR REMITTANCE [PUT A TIC IN THE BOX AGAINST THE ONE OPTED] (@) By postal money order at my cost to address given against item No, 7 () Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation tome S.B. Accounts No. Name of the Bank (in block letters) Branch {in block eters) Full Address Of the Branch {in block letters) SS5EPASIZZE CITI BANK 12. Are your availing pension under EPS-95 ? Iso indicate PPO NO, By Whom Issued. Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE Date 28Lo&) oly Signature B feft Hand ‘Thumb Impression of the ‘Member / claimant(s)ADVANCE STAMPED RECEIPT [To be furnished only in case of (b) above] Received a sum of Rs. (RUPEES. oosesoeses svcioneceatl) ‘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-in- charge) Signature & left hand thumb impression of the member on the stamp Certified that the particulars of the member given are correct and the member has signedithumb impressed before me. ‘The details of wages and period of non-contributory service of the member are as under:- Form 34/7 (EPS) enclosed for the period for which it was not sent to employee's Provident Fund Office) ‘Wages (Basic + D.A) as on 18.11.95(if applicable) ‘Wages as on the date of exit Period of non contributory Service YeeriMonth No.of days ‘Signature of Employer’ authorised Official Date,{FOR THE USE OF COMMISSIONER'S OFFICE) (Under Rs... - a cece secre eo PANO scene Passed for payment fOr RS... eecesee (in words). M.O. Commission (if any)... Net amount to be paid by M.O...... oe towards withdrawal benefit. DH. ss AAO (FOR USE IN CASH SECTION) Paid by inclusion in cheque No... ‘No, 10 Debit item No, Vide cash Book(Bank) Account DH ss AC(Alcs) Forissusif S.§;, IDS is enclosed, DH SS A.A.OIAPFC(Alcs) (FOR USE IN PENSION SECTION) ‘Scheme Certificate bearing the control NO.......sssesetersee sw d8sued On .. ‘entered in the scheme Certificate Conirot Register DH ss AAO APEC(PENSION)Employees’ Provident Fund Scheme, 1952 Forma (Rete tinsractin) Name of the members in Block Letters. (AW LQ hie AL Fathers Name or (husband's Name nthe case ofmaried woman) @ AS KAMAL RAKAL Name & Address of the Factory/Establishment CAMPUS ENT TNDTA PVT LTD. inwhich the memberwasemployed. @\ of 0.05, TIVEOCETY 2. CEC TOK-23 UR AON ‘Account No. su DL AN/ GG N/2 027314 / 000 /00003% Dato ofleavingserviee 22/06 / 2014 6 Reason for leaving service Deined AWOTHEK ComPptwy 7. Full Postal Address (in Block Address) ‘ShirSmtsKum. RASC. BRAT LBA MUKHERTEEL WAG AR Zs DEL KT, ENOTA SIOMVOIDIO... wo, GUE &_ Mode of remittance Puta tick (1) in the box against the one opted (a) By Postal Money Order at my cost. ( ) To the address given against item No. 7 (©) By account payee cheque sent Ww) S.B. Account No. 55%. PPLE Direct for credit to my SB, Name of the Branch. ANI Alc (Scheduled Bank/P.O.) Branch....60d-.L ke, ae NES DEL ML Under intimation to me. Full address of the branch...3.3..DASAMT LOI, VRSANT VEM AR NEW PELET -52 (Advance Stamped Receipt furiished) Cerified that the particulars are true to the best of my knowledge. Date of joining of Establshment...2-.1./..0.5,f, 262. Lemna Date of Bith ... 2B Lh LES. Contribution for the Current Financial Year. Petiod of Period of break Month Contribution | break if any Month Contribution Hany Employee | Emi Total Employee | Employers Total Month | Wages Month | wages epe_|eplepr [rp|epe | ep epr_|relerr [ee [err | ee{(nformation to be umished by the Employer i the Claim Form ie Atested by the Employer) Certified that the above contributions have been included in the regular monthly remittances. ‘The Applicant has signed/Thumb impressed before me. ‘Signature of LefRight hand thumb impression of the member Date... Designation & Seal Encl Declaration of non-employment Note Inthe ase of submission of aplication fo stement under couse (s) of sub-paragraph () and in ause () of sub-paragraph (2) of paragraph 69 of the EPF Scheme, 1982, he aay eos we Submited after two months fom the date of leaving service provided the’ mierior ee ee cee Temain unemployed in an estabishment to which the Ax septsg, pater? L 26/201 4 Signature ight hehd thumb impression of the member ADVANCE STAMPED RECEIPT (To be furnished only in case of &(b) above) Received a sum of Rs. Re Regional Provident Fund Commissioner / Offcerin-Charge of Sub-AScounts Office 7 by deposit in my Savings Bank account towards the settlement of my Provident Fund Acsourt ‘The space should be feft blank which shall be filed in by Regional Provident Fund Gemmissioner/Otficer in-Charge of S.A.0. Signature orLeft/ Right hand thumb impression of the member (For the use of Commissioner's Office) NC Settied in partFull Entered in F. 24-4249 & withdrawal register Clerk Section Supervisor WO Rheqe ———— Aonount NO, ~--—-—--— Section passed for payment for Ré-—————~- Sin Wt M.O. Commission (any) AOCIAPFC-——— Net Amount be paid BY M0. Date PINo—————— (For use in Cash Section) Paid by inclusion in Cheque Nowru:nsesrnrsinnm ~ date... Vide Cash Book (Bank) Account No.3 Debit item No. " He AC /RC Remarks