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Guidelines For Filling The Pension Form
Guidelines For Filling The Pension Form
erial No:
2. Date Of Birth
a) Father" _ I arne
b) Husband's arne
(If applicablej
5. ~~ ..a.. II l' 10
Code No. & A count No. MHIB '/48475/ _
,~ob rJ~. }-
~\) ~ .....
8. Are you willing to accept'cheme
(a
(o)
Certificate in lieu of withdrawal bcnefil';
Yes 0 o
(b) ominee
10. In case of death of membcr after attaining the age of 58 years without filling the claim:-
II. MODE FOR REM rrrA i CE (I' T A TIC IN THE BOX AGAI 1."1''1'1 IE 0 E OPTED]
(a) By postal money order at m}' cost to addrcss given against item NO.7
(b) A ount payee cheque sent direct for credit to my SB Ale ( "cheduled Bank) under
intimation to me;
1
. B. Accounts j o. :.J
Name of the Bank ---_ ... ~-_._._----
(in block Ictters)
Branch
(in block letters)
Full Address Of the Brdnch
12. Arc your availing pension under EP5-95'1
Ifso indicate pro NO... By Whom issued _
Certified THAT TIlE PARTl Li\RS ARE TRUE TO TilE BEST OF MY KNOWLEDGE.
Date:
~~ ~e-
Signature or left hand thumb
I In pression of the mem ber/c1aimant
AD AJ 1 E STAMPED RECEIPT
ITo be furnished only in casc of (h) abovcl
(The pace houJd be len blank which shall be filled by Regional Provident Fund Commissioner IOfficcr-
in- harg')
'ignalure & left hand thumb impression of the member on the 'lamp
el1ified that the particulars orthe member given arc correct and the member has signed/thumb impre sed
before me.
The detail of wages an'd period of non-contributory service of the mcmber are as under:-
Form 3A17 (EP ) endo ed for the period for which it was not sent to employee's Providcnt Fund Office)
(Under Rs .
P.1. 0 '" "'1. o.le hcquc
D.H.
5.S.
A.A.O
Paid. by mclu
. '. III c hequc N 0........................
Ion [)t vide ea..h Book (Bank)
. Account
o. 10 Dcbit item No .
eheme Ccrti ficate bearing the control No . ..1 'sued 011 .................. and
entered in the scheme Certificate Control Rcgister-
A.P.F.C. (pENSION)