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EPF Form10-C Ashok

Ashok Mangalore is submitting a form to claim withdrawal benefits from the Employees' Pension Scheme 1995. He worked at Cubic Transportation Systems India Private Ltd in Hyderabad until resigning in July 2012. He is married with one son named Chinmay. He is requesting his withdrawal benefits be deposited into his savings bank account at HDFC Bank in Hyderabad. The form includes details of his employment, family, and bank account information to process his claim.

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K Srinivasa Rao
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206 views3 pages

EPF Form10-C Ashok

Ashok Mangalore is submitting a form to claim withdrawal benefits from the Employees' Pension Scheme 1995. He worked at Cubic Transportation Systems India Private Ltd in Hyderabad until resigning in July 2012. He is married with one son named Chinmay. He is requesting his withdrawal benefits be deposited into his savings bank account at HDFC Bank in Hyderabad. The form includes details of his employment, family, and bank account information to process his claim.

Uploaded by

K Srinivasa Rao
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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EMPLOYEES PENSION SCHEME, 1995 Form 10-C (EPS) Form for claiming withdrawal benefit / Scheme Certificate

(Read INSTRUCTIONS before filling in this form)

1 (a) Name of the Member: ASHOK KUMAR MANGALORE (In Block Letter) (b) Name of the claimant(s): 2 Date of Birth: 01/06/1971 3 Marital Status: MARRIED 4 (a)Fathers Name: L.S. MANGALORE (b) Husbands Name: (if applicable) 5 Name & address of the Establishment in which, the member was last employed:
CUBIC TRANSPORTATION SYSTEMS INDIA PRIVATE LTD., H-08, LEVEL 1, MODULE 1, L T PHOENIX INFOPARKS PVT. SEZ HITECH CITY 2, GACHIBOWLI, HYDERABAD 500081

Region/SRO Code Esstt. Code No. AP/HYD/63640 A/c. No. 6 Establishment Code No.: AP/HYD/63640 & Account No.: AP/HYD/63640/26 7 Reason for leaving service & Date of leaving: RESINGATION, 31 JUL 2012 8 Full Postal Address (In Block Letters) Shri/Smt./Kum./S/o / W/o / D/o
Ashok Mangalore, 301, II B BLOCK, SMR VINAY ACROPOLIS, WHITEFIELDS, KONDAPUR, HYDERABAD - 500081 PIN: 500081

9 Are you willing to accept Scheme Certificate in lieu of withdrawal benefits? (a) Yes ( ) (b) No ( ) 10 Particulars of Family (Spouse & Children & Nominee) Name Date of Birth Relationship with Member Name of the Guardian of Minor Savita 28/08/177 Spouse Chinmay 23/11/2005 Son Savita (A) Family Member: Savita (B) Nominee: Savita 11 In case of death of member after attaining the age of 58 years without filling the claim : (A) Date of death of member : _________________ (B) Name of the Claimant(s) / and relationship with the members _______________ 12 MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ONE OPTED)

(a) Bypostal 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 / Co. Operative Bank/Post) Under intimation to me. ( )
S.B. Account No.: 05451050153253 Name of the Branch: HDFC BANK LTD., Branch: MADHAPUR Full address of the branch:
GR FLOOR, CYBER HEIGHTS PLOT NO 30 ROHINI LAYOUT, OPP CYBER TOWERS, HITEC CITY, MADHAPUR HYDERABAD 500081 ANDHRA PRADESH

13 Are you availing Pension under EPS-95 ? If, so, indicate : PPO No.______ _____________By whom issued ________________________________ CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE Date: 25 October 2012
ASHOK MANGALORE

Signature or left Hand Thumb impression of the Member/Claiment(s) ADVANCE STAMPED RECEIPT (To be furnished only in case of 12(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 / Officerin Charge)
Affix Re.1.00 Revenue Stamp

ASHOK MANGALORE

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 signed / thumb impressed before me. The details of wages and period of non-contributory service of the member are as under : Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employees Provident Fund Office.) Wages (Basic + D.A.) as 15-11-95(if applicable): Wages as on the date of exit: Rs. 75,000.00 Period of non contributory Service Year/Month/No. of Days: Nil

Date: 25 October 2012

Kishan Rao K

Signature of Employer / Authorised Offical

(FOR THE USE OF COMMISSIONERS OFFICE) (Under Rs. _________________________ P.I. No. ________________________ ___________________________________M.O. / Cheque / Passed for payment for Rs. _____________________________ (In Words Rupees) ______________ _________________________________________ M.O. Commission (if any) _______________________ / net amount to be paid by M.O. ____________________________________towards withdrawal benefit. D.H. S.S. (FOR USE IN CASE SECTION) Paid by inclusion in Cheque No. ________________ Dt. _________________ vide cash Book (Bank) Account No. 10 Debit Item No. ___________________ D.H. For issue if S.S,: IDS is enclosed. S.S. AC(A/CS) A.A.O.

D.H.

S.S. (FOR USE IN PENSION SECTION)

APFC(A/cs)

Scheme Certificate bearing the Control No. ______________ Date ___________ Issued on and end entered in the Scheme Certificate Control Register. D.H. S.S A.A.O. APFC(PENSION)

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