Emp.
Code :-
FORM 10 C (EPS)
EMPLOYEES’ PENSION SCHEME, 1995
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWL 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 : ________________________________________________
2) Date of Birth : ____/____/______
3) a) Father’s Name : _____________________________________________
b) Husband’s Name (if applicable) :
4) Name & Address of the Establishment HDFC BANK LTD.,
PAD - FINANCE,
LODHA - I THINK TECHNO CAMPUS
BUILDING - ALPHA, 8TH FLOOR,
NEXT TO KANJUR MARG RAILWAY STATION (EAST),
KANJUR MARG (E), MUMBAI 400042
In which, the member was last employed. :
5) Code No. & Account No. : MH / 46135 / ______
6) Reason for leaving service : Resigned
& Date of leaving : ____/____/______
7) Address : ________________________________________________
_____________________________________________
_________________________________________________
Tel : Number ______________ Moblie No. _____________________
E-Mail ID ______________________________________________________
8) Are You willing to accept Scheme
Certificate in lieu of withdrawal benefit : Yes
No X
Particular of Family (Spouse, Children & Nominees)
Family Member Name Date of Birth Relationship With Member Name of the guardian of minor
9) Incase of death of member after :
attaining the age of 58yrs without
filling the claims
(a) Date of death of member : ________ __________________________________________________
(b) Name of the Claiment(s) and
Relationship with the member : ________ __________________________________________________
10) MODE OF REMITTANCE (PUT A TIC IN THE BOX AGAINST THE ONE OPTED)
A) By postal money order at my cost to the address given against item no 7.
N/A
B) By account payee Cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation to me.
Saving Bank Account No. : _________________________________________________________
Name of the Bank (In Block letter : _________________________________________________________
Branch Name (in Block Letter) : _________________________________________________________
Full Addresses of the Branch : _________________________________________________________
(In Block Letters)
_________________________________________________________
11) Are your availing pension under EPS-95
If so, indicate ` : ______________________________________________________________
_________________________________________________________________________________________________________________
CERTIFIED THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date ____/_____/_______ Signature or left Hand Thumb Impression of the Member / Claimant
__________________________________________________________________________________________________________________
13) ADVANCE STAMP RECEIPT
( TO BE FURNISHED ONLY IN CASE OF (B ) ABOVE )
RECEIVES A SUM OF Rs. _________________ (Rupees _______________________________________________________only) from
Regional Provident Fund Commissioner / Officer In Charge of Sub – Regional Office____________________ by deposit in my saving
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 / Office-in-Charge)
Afix Rupee 01
Revenue Stamp
Signature or left Hand Thumb Impression of the Member / Claimant
MH/46135/
(FOR THE USE OF COMMISSIONER’S OFFICE)
(Under Rs. _______________________ P.I ____________________M. O/ Cheque passed payment for Rs. ________________________
(in words _________________________________________________________________ M. O ( if any)_______________________________
Net amount to be paid by M.O ______________________ towards withdrawal benefit
C.C S.S A.A.O
(FOR USE IN CASH SECTION)
Paid by inclusion in cheque No.______________ Dt.____________vide cash Book (Bank) Account No. 10 Debit item No._____________
S.S A.C (CASH)
For issue of scheme Certificate, Input Data Sheet is enclosed
C.C 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.
C.C S.S A.A.O APFC (Pension)
