Professional Documents
Culture Documents
PF Claim Form
PF Claim Form
in
मोबाईल सं
Mobile Number
(ख / b):
(ख / b) पवत का िाम / Husband’s Name
3. जन्म वतवि / Date of Birth
* के िल 5 िर्म से कम की सेिा अिवि के मामले में/Only in case of service less than 5 years
10 पत्र-व्यिहार का पूरा पता / Full Postal address
....................................................................................................
....................................................................................................
....................................................................................................
Pin वपि..............................
11 भुगताि की विवि / Mode of payment: बचत बैंक खाता सं/Saving Bank Account No.
िांवछत दकसी एक कोष्टक में टिक लगाएं ( √ )
Put a ‘Tick’ against the one opted (√ ) …………………………………….………………………………….....
सदस्य द्वारा यह घोर्णा की जाती है दक िह दो माह से कहीं काम िहीं कर रहा है ( हााँ / िहीं ) / The member hereby declares that he has not been employed for two months (Yes/No.)
प्रमावणत दकया जाता है दक मेरी पूणम जािकारी के अिुसार उपरोक्त वििरण सही है / Certified that the particulars are true to the best of my knowledge.
प्रािी िे मेरे सामिे हस्ताक्षर दकए / अाँगूठा लगाया है / The Applicant has signed/thumb impressed before me.
क्षेत्रीय भविष्य विवि आयुक्त से अपिे भविष्य विवि खाते के विपिाि पर `……................................................................ की रावश अपिे बचत बैंक खाते में प्राप्त की ।
Received a sum of `.…………………………..……………from Regional Provident Fund Commissioner by deposit in my Saving Bank account towards the
Kindly do NOT paste revenue stamp in case of payments through NEFT / Electronic mode.
कृ पया एि.ई.एफ.िी. /इलेक्ट्राविक माध्यम से भुगताि होिे के मामले में रसीदी टिकि ि लगाएं।
खाते का विपिाि दकया गया । फामम सं 21 –ए /2 तिा प्रत्याहरण रवजस्िर / 3 प.पै.वि. प्रपत्र 9 ( संशोवित ) में प्रविवष्ट की
Account settled in Part/Full Entered in F-21-A/2 and Withdrawal Register / Form 3 (F.P.F.) Form9 (Revised)
के भुगताि के वलए पास दकया / Passed for payment for ` :………………………………. िी.डी.एस. /TDS Rate %: ……………
शुद्ध रावश मिीआडमर द्वारा दी जािी है / Net Amount to be paid by M.O. Accounts Officer
ददिांक/ Date :
____________________________________________________________________________________________________________________________________________
fudklh ifjYkkHk@;kstuk izek.ki= ds nkos gsrq iz;ksx fd;k tkus okyk izi= 10 lh
FORM 10C FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
deZpkjh is”a ku ;kstuk] 1995 EMPLOYEES’ PENSION SCHEME, 1995
izi= Hkjus ls igys funsZ”kksa dks i<s+a@(Read the instructions before filing up this form)
;fn lnL;rk 180 fnu ¼xSj va”knk;h lsok dks NksM+ dj½] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA WITHDRAWAL BENEFIT IS NOT ADMISSIBLE IF
MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRIBUTING PERIOD
1. ¼d½ lnL; dk uke ¼Li’V v{kjksa es½a @ Name of the Member (In Block Letters): ____________________________________________
¼[k½ nkosnkj dk uke
Name of the claimant (s): ______________________________________________________________________________
4. LFkkiuk dk uke o irk ftlesa lnL; var esa fu;ksftr FkkA@ __________________________________________________________
Name & Address of the
Establishment in which, _______________________________________________________________________________
the member was last employed
5. dksM la- rFkk [kkrk la- {ks=@ dk dksM LFkkiuk dh dksM la- [kkrk la-
Code No. & Account No. Region/Off Code Estt. Code No. A/c No.
# lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fu”kku # fu;ksDrk ds gLrk{kj /Employer’s Signature
Signature or Left / Right hand thumb impression of the member
Form 10C (www.epfindia.gov.in ) Page 1 of 4
8. D;k vki fudklh ifjYkkHk ds LFkku ij ;kstuk gkWa Yes ugha No
izek.ki= Lohdkj djus ds fy, rS;kj gSaA
Are you willing to accept Scheme Certificate
in lieu of withdrawal benefits
;fn lnL;rk 180 fnu ¼xSj va”knk;h lsok dks NksM+ dj½] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA
Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service.
¼[k½ ukfefr
(b) Nomine
10. fcuk nkok fn, 58 o’kZ dh vk;q izkIr djus ds ckn lnL; dh e`R;q gksus ij] %&
In case of death of members after attaining the age of 58 years without filling the claim:-
¼d½ lnL; dh e`R;q dh frfFk@Date of death of the member
¼[k½ nkosnkjks ds uke@rFkk lnL; ls mldk laca/k@Name of the Claminant(s)/and relationship with the member
11. /kuizs’k.k dk ek/;e ¼fodfYir fof/k ds vuqlkj lacaf/kr dks’Vd esa fVd djsa½
Mode of remittance (put a tick in the box against the one opted)
¼d½ en la- 7 esa fn, irs ij esjh ykxr ij Mkd euhvkMZj }kjk
By postal money order at my cost to the address given against item No.7:
¼[k½ eq>s lwfpr djrs gq, esjs cpr [kkrk la-¼vuqlfw pr cSad@Mkd?kj½ esa js[kfdar psd@ bysDVªkWfud ek/;e ls vknkrk [kkrk lh/ks Hkstk tk,@ (b) By account
payees cheque/ electronic mode sent Directly for credit to my S.B. A/C (Scheduled Bank /P.O.) under intimation to me.
cSad dk uke ¼Li’V v{kjksa esa@Name of the Bank (In Block Letters) : ________________________________
______________________________________________________________________________________
12. D;k vki d-is-a ;ks- 95 ds rgr is”a ku izkIr dj jgsa gSa \
Are you availing pension under EPS-95 \ gka@Yes ugha@No
;fn gkWa] rks bafxr djsa ih-ih-vks- la- fdlds }kjk tkjh
If yes, indicate PPO No………………. By whom issued………………………………………………………..
izekf.kr fd;k tkrk gS fd fooj.k esja s vf/kdre Kku ds vuqlkj lR; gS@
a Certified that the particulars are true to the best of my knowledge
is”a ku fuf/k [kkrs ds fuiVku Lo:i {ks=h; Hkfo’; fuf/k vk;qDr@mi&{ks=h; dk;kZy; ds izHkkjh vf/kdkjh ls vius cpr cSad [kkrs esa tek }kjk
₹ ----------------------------------------- ¼”kCnksa es½a --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------½ dh jkf”k izkIr dhA
Received a sum of ₹........................................ (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 Account.
ck¡;h rjQ fn, fjDr LFkku dks {ks=h; Hkfo’; fuf/k vk;qDr@izHkkjh vf/kdkjh }kjk Hkjk tk,xkA
The space should be left blank which shall be filled by Regional Provident Fund
Commissioner/Officer-in-charge)
₹ 1 jktLo fVdV
₹ 1 Revenue
fVdV ij lnL; ds gLrk{kj vkSj ck¡; gkFk ds vaxwBs dk fu”kku Stamp
Signature & left hand thumb impression of the member on the stamp
izEkkf.kr fd;k tkrk gS fd lnL; }kjk fn, fooj.k lgh gS vkSj lnL; us esjs le{k gLrk{kj fd, gSa@vaxwBk fu”kkuh yxkbZ gSA
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.
lnL; dh etnwjh ,oa xSj va”knk;h lsokof/k ds fooj.k fuEukuqlkj gSa %&
The details of wages and period of non-contributory service of the member are as under:
¼izi=&3,@7½ ¼d-is-a ;ks-½ ml vof/k dk layXu gS ftl vof/k gsrq ;s deZpkjh Hkfo’; fuf/k dk;kZy; dks Hksts ugha x, FksA½
(Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employees’ Provident Fund Office)
fnukad 15-11-95 dks etnwjh ¼ewy osru + egaxkbZ HkÙkk½ ¼;fn ykxw gS½ ₹
Wages (Basic +D.A.) as on 15.11.95 (if applicable)
lsok R;kxus dh frfFk dks etnwjh
Wages as on the date of exit ₹
psd la- ----------------------------------------------------------------------------------------------------------------------------- --------------- fnukad --------------------------------------- }kjk lans; ftls udn iqfLrdk ¼cSad½ [kkrk
;kstuk izke.ki= ftl ij fu;a=.k la- ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- mfYyf[kr gS] dks fnukad -------------
-------------------------------------------------------------------- dks tkjh fd;k vkSj bldh izfof’V ;kstuk izek.ki= fu;a=.k iath esa dhA
8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :
21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax Area Code AO Type Range Code AO No.
(if not assessed to income tax earlier):
22] Estimated total income from the sources mentioned below: (Please tick the relevant box)
Dividend from shares referred to in Schedule - I
Interest on securities referred to in Schedule - II
Interest on sums referred to in Schedule - III
Income from units referred to in Schedule - IV
The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 to be included:
24] Details of investments in respect of which the declaration is being made :
SCHEDULE‐I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of Class of shares & face Total value Distinctive numbers Date on which the shares were acquired
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)
SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Date(s) of Date(s) on which the securitues were
Amount of securities
securities securities securities (dd/mm/yyyy) acquired by declarant (dd/mm/yyyy)
SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Name and address of the person to Amount of sums Date on which sums given Period for which sums
Rate of interest
whom the sums are given on interest given on interest on Interest (dd/mm/yyyy) were given on interest
SCHEDULE‐ IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Class of units & face Distinctive number
Name and address of the mutual fund Number of units Income in respect of units
value of each unit of units
SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the Date on which the account The amount of withdrawal
National Savings Scheme is maintained and the account number was opened (dd/mm/yyyy) from the account
x
Signature of the Declarant
Declaration / Verification
PART - II
[For use by the person to whom the declaration is furnished]
1] Name of the person responsible for paying the income referred to in Column 22 of
2] PAN of the person indicated in Column 1 of Part II
Part I :
8] Date on which Declaration is 9] Period in respect of which the dividend 10] Amount of
income paid : 11] Date on which the income has been
Furnished (dd/mm/yyyy) : has been declared or the income has been
paid / credited (dd/mm/yyyy) :
paid / credited :
8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :
21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax Area Code AO Type Range Code AO No.
(if not assessed to income tax earlier):
22] Estimated total income from the sources mentioned below: (Please tick the relevant box)
Dividend from shares referred to in Schedule - I
Interest on securities referred to in Schedule - II
Interest on sums referred to in Schedule - III
Income from units referred to in Schedule - IV
The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 to be included:
24] Details of investments in respect of which the declaration is being made :
SCHEDULE‐I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of Class of shares & face Total value Distinctive numbers Date on which the shares were acquired
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)
SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Date(s) of Date(s) on which the securitues were
Amount of securities
securities securities securities (dd/mm/yyyy) acquired by declarant (dd/mm/yyyy)
SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Name and address of the person to Amount of sums Date on which sums given Period for which sums
Rate of interest
whom the sums are given on interest given on interest on Interest (dd/mm/yyyy) were given on interest
SCHEDULE‐ IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Class of units & face Distinctive number
Name and address of the mutual fund Number of units Income in respect of units
value of each unit of units
SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the Date on which the account The amount of withdrawal
National Savings Scheme is maintained and the account number was opened (dd/mm/yyyy) from the account
x
Signature of the Declarant
Declaration / Verification
PART - II
[For use by the person to whom the declaration is furnished]
1] Name of the person responsible for paying the income referred to in Column 22 of
2] PAN of the person indicated in Column 1 of Part II
Part I :
8] Date on which Declaration is 9] Period in respect of which the dividend 10] Amount of
income paid : 11] Date on which the income has been
Furnished (dd/mm/yyyy) : has been declared or the income has been
paid / credited (dd/mm/yyyy) :
paid / credited :