7521 1 ‘wai d./Serial No, opted teh Pagods GseNo ADaYo ota, 1 0-at efien pratertta ara & fq, | For Otfeo Use only Form No. 10-C (E.RS.) Torso ee nna, “EBi,Iho Hoi SHO, 1995 wofant deter (@) aisieil, 199 5. = EMPLOYEES’ PENSION SCHEME, 1995. 8S Hottbm HAPs IoFaj/SGS0 $5829, BhodomeStH0, ABM foo Podio SG60,| 1995 200 Sgashs LOAF Nobis pats. swt raft, 1995 eee ae Peet ee / sere fe see a Ty FORM'TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE (ot arvsatonas $18 Bb roti aothotn Kedwoi SI0a) (quent a) ped & urd sgh a} WR UY (Road the instructions before filing up this. form) Employee, Employer, 1.3) Seagaheg (28 ernest) Rey 8) Name ot the Member (Block fe ®) & (v) Se. a) meets ate b) Name of Claimants) 2 (a) Sagsdq / w= Ff / Date of Birth Sieo [Days 32] Month Baseyse/ Year (b) Martal Status — 3.3). Lassa See (sgonsst) 8) Roraran/ aft ara (setae) a) Father's: Name, | Husband's Nemes! : cable) 4. Beste. iso emote : Soy SavS, oF ot Ro / Ferien, em eTsty. dem! we don ee Sen eeu Est. Code No., A’c No. code No reat Ne AP, / ease ONbIGm SOEs weg ee, Oto ae Name & ‘of the as Establishment in which, the member was last employed. 1a), S05 80065 : ard we Date of Joining 6 seqetsepage ons 30 / ARR RRA AAT: 1 OF at Comet Date of membership joining the Fund ————— eee ta) KOgie Sood BET onSotats erdeve SwoaO BENS BO : 7 beds beulerk bol so ‘ . on Sih Reason for loving sorvce & Date of faving 7. Ergadre Doms (24 exero6*) Pe gee Teme: pr — (ere wet) Ful Postal address a (WnBlock Loters) B/gp20/ 8870 A het gr (shivsmur) ct fg [9B ; piste BES Ro/AH/PING S/0, We, Oo 4. GiScthon GemERDE BoLeNM SHE GARI Bote pot te wohtORe 2 ‘eve ret a walt TON AAT TR penser igen crits wre] oT] memes : = 9. Busgy Buen (wes/9g sda Nees, aod Sy) ea er (a ee a AT) Particuars o Family (Spouse & Chikren & Nominee) eysde Seageet ts Beast Seo Se0/FE/ Name aa fie resco + Sate geee at Date of Beth ween aR aan tute arte os suman of Minor 2) ih (ae Nonree : 8) munessage : 2s) stenicezen 2) Famly Members 7 2») a) 2. fostas seam arpa Hees Sao 58 Sosouoe Hats OAS RESEND Sst OdG ogEPOET : Samer ong & HA acer wht Ror ae AEG OA T: Incase of death of member aftr attaining the age of 68 years without ing the claim wags etree bs | HEU AEG AFAR Date of doath ofthe member ‘teasvoss0(o) hes sesgest ne'sowogd TART at / wm weeE BIT eat / Nar che Cass nanos we mabe Beige Horse (tote Ses Daa es ensge* edu, (7) mtg Sy0d. Sra gt atin (Freea a orgee FER ort a ceER) [MODE OF REMITTANCE (PUT A TICK ( ) INTHE BOX AGAINST THE ONE OPTED) 2) Be. 7 ote ob aS Stam a SQODT BOSD UY aI we) me den 7 ont REA TTR wa eh ac 1) Bypastal money order at my cast the address given against tem No.7 0) Banjos enjonsta Snell angots oT,orw Sous eisetoenad is DESIR HUM otw how Be] 0" Soird. a) afer ach f agafe He B Maas fe UT eS fo fen wh once er oe '») Account payes cheque sent crect for ered to my SB Ale (Schedule Bank) Under itimation tome. Boer pis Bowe. waa aia Hn/ S.B. Account No. anor Sts (2a exorost) aa sian (ere oad) "Name ofthe Bank (n book letters) orp bes (28 expos") “mTaI/ Branch (n block laters) eo) mre re (ee Seat) Full Address of the Branch ShaG, 1995 Bots ee Fests Domasane 7 eas 25009 Dated. ‘wo ore miet der ha, 1995 Sormiste dat ‘Are you avaing pension under EPF 95 7 ommeet taf et 6. Se, / A.M. vi, OR/PPO No. 90, indicate 250 S005 er0 Satoesdss0/ fara Wt / By whom issued. ter er sn frre aetna ore tga wh E CERTIFIED WAT THE PARTICULARS ARE TAUETOTHE BEST OF MY KNOWLEDGE Sore / Dato YP scaredonepffesswotse (0) dais $0 5 GOS wee / ert em Tg Be si wo PT “Signature or Left Hand Thum inpresion of the Member /lamantea) 3wos,my, ago Ft afi F121 12 e_/ AWANCE STAMPED RECEIPT QS BOBS (2) voto Mav0d* Sr|¥h FdaddaoSed twos) / (Stet (a) HT ‘at Mega HE ) / (To be furnished only in case of (b) above) SY: Rowegads boss Hots UT row Adeoes Diivos" Stok enfots UT ound Adu Sesto ager 7 bets wigDp EEMAEs | os Grobe mayucivo aSPQ wOHO Sod Or (arrreives eros. ~) Ryseosaso. 2 Le wae omg / a Stree S wort aed gre es Be ane Ree Sarena aan de oa wear fre Receivedasumolfs (Rupees _ ‘only rom Regional Provident Fund Commision /Otficr incharge of Sub-Regional tice by deposit in my savings Bank A/c towards the settlement of my Pension Fund Account grobew wingng saat /ubsee aSing as ats mts yngtaire. (Seare a) ert we AS ate wes AR MRR / Hu sete x seem) (Te space shoul! bell blank which shallb2 lad by Regional Provdent Fund Commissioner /Oficern-charge) BoP Seege soawe soste uss Sts gO sop. ae fee Rees peer she ard Te SH TAT Revenue ‘Signature & Let Hand Thumb Impression ofthe member onthe stamp. Stamp {Deiepte DBSSWOS Bre SHEARS Hoan w Shales wwe Hoste /Sding Sead QaOSe END. sea fret are weer ee Fern eth ee ee CE / gS a ere Certified thatthe particulars ofthe member given are comect and he rember has signed/ thumb impressed before me. Hove tore ages Dowe BBosD SbGwMcD Ae Be bod Bom Ayo. werght aun eee orient den & Racor sre reget Ast C0 BIO PoyEAINDS BoKD END! No Dieress Sue Ron 39/7 soko (ome 3 / 7 (eA eR.) Se rat mr ier fe rae eer eect) wire FARE referee ae AR Me) (orm 3 A/7 (EPS) enclosed forthe period for which twas nt sent to Employees’ Provident Fund Office) sho sud 325 SA weds Sores : Bis BRA Gt Rs. ‘Wages ason te date of ext /eaving a Is-11-951mMgO (Re dea + wim) (eReMA) [Ay Wages (Basic + B.A.) as on 15-11-95 it applicable) el Bowe Dosdishgio mee rire ar a Period of Non-contributory Service (Breaks in Service) ‘SeSgyBe,3e /-at / mm /Year/Montn Siero Song / fea Hee / No. of Days Particulars of Breaks month-vise should be fumished in From Dats of Joining to to Date of Leaving Sarvice, Bey caren’ / Uday UOPOPTTO * Braham / stage afar as rear Signature St Empoyery-Autnonsee-sftcial 4 ‘ofthe Est. with Seal & Date Dou te 6.1906 sere w BOL a separate statement! 15-19-1095 & 16-11-11(Sarai WOR,OdL SHaemygo) (arrqaer arava acta & Fee) (FOR THE USE OF COMMISSIONER'S OFFICE) (or etagedtic) Banter 88 eyes Bey, age. (exes) 2Ysoe soars Hamer, orate _ _ A ata, (owt) __ Ss gemtgata weno. APJ (Under M.0./ Cheque. Passed for payment for Rs, (in words) Rupees. ssh ope same SBS eed ov. Rage ____esscintin gatnasoftio do.t.go agosre 06 swf oretcaiers (Se) wf seat mata Raa oi, MO. Commissioner (tan. net amount tobe paldby MO. _ towards wiharaval benef PINo. Scroll No. Date :_ _ 6,3. 1A. 38.08. /a8./8.8, 2.0.6. (TAT IAAO, QSo BQoh DFHOSF KSBP60 DEG0) (pom argent i sci & fera) (FOR USE IN CASH SECTION) 09 BNe (-nGets) oP jouw Zo: 10 og 48, Kos, 3, ea BgOsEBSO. ‘deg ath (4s) Ti en 10% Fee we doer aes | sient ee ee fea A rer ye gras fleet rer Pid by inclusion in Cheque No. o_o Cash Book (Bank) ‘Ascourt No, 10 Debk tam No, 2d. find 26.08. /aH./5s. 3b (SKB) [wx aM. (THe)/APFC (Cash) ec a a aia ah A eatin a) 2555 ent ange adates erssseryse, eat sarong ah att act & fey rage ZT He Hem | / For issue of S.S.; IDS is enclosed. aa 36 3... E(oryorR) aHIDA. aa/S8. BAIAAO ‘a ft.an, (3am) / APEC (Ales)Lotte DF 605s 4SBPG0 aabo (ee argue san re) (FOR USE IN PENSION SECTION) Eis veystes Beute byes Gisigse oa Ky 4 Rai, ee ae seo ard fear nent te Aim serene Fey Pe fran en Scheme Cerificate bearing the contol No. _ ‘entered inthe Scheme Ceriticate Control Register. ao BS oot BHO (Loss) ABTS /D.A, B5./8.8. WAwIAAO, ‘3.3.8.3. (Ht) / APEC (Pension)