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Employees' Pension Scheme, 1995

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 member's name and date of birth, employment details, reason for leaving, family details, mode of payment, and pension details if applicable. It includes sections for office use to process the claim, make payment, and issue a scheme certificate. In summary, it is a form for former employees to claim their pension benefits from the Employees' Pension Scheme 1995.

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190 views4 pages

Employees' Pension Scheme, 1995

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 member's name and date of birth, employment details, reason for leaving, family details, mode of payment, and pension details if applicable. It includes sections for office use to process the claim, make payment, and issue a scheme certificate. In summary, it is a form for former employees to claim their pension benefits from the Employees' Pension Scheme 1995.

Uploaded by

prakash_6849
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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1

E Code ____________ PF Code _________________ Serial No:




Mobile No _________________ Form No 10 C (EPS)
E mail ID _________________


EMPLOYEES PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THEEMPLOYEES PENSION SCHEME,
1995 FOR CLAIMINGWITHDRAWAL BENEFIT/ SCHEME CERTIFICATE
(Read the instructions before filling up this form)


1 a) Name of the member
( in block letters )
b) Name of the claimant(s)

2 Date of Birth

3 a) Fathers Name
b) Husbands Name (if applicable)

4 Name & Address of the Establishment in
which, the member was last employed







5 Code No. & Account No Region/SRO Code

Estt. Code A/c No.


6 Reason for leaving service :
& Date of leaving
Resignation

7 Full Postal Address
(in Block letters)


Sh/Smt./Km
S/o, W/o, D/o
PIN




For Office Use Only
In Words No.
2

PF Code _________________

8. Are you willing to accept Scheme (a) (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 Guardian Name
of the Guardian
a) Family
members




b) Nominee





10. In case of death of member after attaining the age of 58 years without filing the claim
a) Date of death of the member
b) Name of claimant (s)/ and relation-ship with the member

11. MODE OF REMITTANCE [PUT A TICK IN THE BOX AGAINST THE ONE OPTED]


a) By postal money order at my cost to the address given against item No. 7


b) Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under
intimation to me)


S.B. Account No
Name of the Bank (In block letters)
Branch (In block letters)
Full Address Of the Branch (In block letters)



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



Dated .
Signature or left Hand Thumb impression of the member/Claimant(s)






3




PF Code ____________________


ADVANCE STAMPED RECEIPT

[To be furnished only in case of (b) above]


Received a sum of Rs. ________________ ( 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.


(The space should be left blank which shall be filled by Regional Provident Fund Commissioner

/ Officer-in-charge)


Signature or left hand thumb impression of the member on the stamp
Re. 1
Revenue
stamp




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 as under:-

Form 3-A/7 (EPS) enclosed for the period for which it was not sent to Employees Provident Fund Office.


Wages (Basic + D.A.) as on 15.11.95 ( if applicable) :

Wages as on the date of exit :

Period of non-contributory service

Year/Month No.of days

Signature of Employer/
Authorised Offical
with seal
Date:

4

PF Code ____________________

( FOR THE USE OF COMMISSIONERS OFFICE )


( Under Rs. ___________________________________________________________________

P.I. No. _____________________________________________________ M.O. / Cheque


Passed for payment for Rs. ____________________(in words)__________________________

___________________________________________________________________________________

M.O. Commission (if any) __________________ net amount to be paid by M.O. ___________________

towards withdrawal benefit.




D.H. S.S. A.A.O

( FOR USE IN CASH SECTION )



Paid by inclusion in cheque No. _______________ Date ___________ vide cash Book (Bank) Account

No. 10 Debit item No. ____________________________



D.H. S.S. AC(A/cs)


For issue of S.S.; IDS is enclosed.



D.H. S.S. A.A.O. / APFC(A/cs)


( FOR USE IN PENSION SECTION )



Scheme Certificate bearing the Control No. __________________ issued on ____________ and

entered in the Scheme Certificate Control Register:




D.A. S.S. A.A.O. APFC(PENSION)

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