PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE YOU FILL FORM 10 C
1.
a. Your name as per record and bank account
b. Your name as per record and bank account
2. Date of birth
3. Fathers name, Husband Name if applicable
4. Establishment name and address: Already provided
5. EPS account number KN/10088/ PF number as per salary slip.
6. Reason for leaving & Date of leaving: Resigned. Please do not enter any other
reasons. Date of leaving Infosys.
7. Full postal address: You need to give full postal address with pin code. Mobile No.
is mandatory to convey you the settlement status by Regional PF office.
8. Scheme Certificate: if your service is more than 10 years then tick YES
Otherwise, No
9. Nomination: any one of your family member.
10. Not applicable
11. You need to give full bank account number and branch address and
attached a copy of cancelled cheque .
12. Not applicable.
Signature: Please sign on two portions.
1. Below the text CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF
MY KNOWLEDGE
2. Below ADVANCE STAMPED RECEIPT. No Revenue stamp is required.
Infosys
Employee No.
Form No.10 C (E.P.S)
For Office Use only
Inward No. :
EMPLOYEES PENSION SCHEME 1995
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME 1995 FOR
CLAIMING WITHDRAWAL BENEFIT SCHEME CERTIFICATE
(Read the instruction before filling of 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 and address of the
Establishment in which the member
was last employed
Infosys Technologies Limited
Plot No.44 & 97A, 3
rd
Cross,
Electronics City, Hosur Road,
Bangalore 560 100
5. EPS Account No.
KN/ BN/ 10088
6.
Reason for leaving service
& Date of leaving
:
:
7. Full Postal Address (in Block Letters) :
Sri/Smt/Kum
S/o. D/o. H/o. W/o. :
Mobile No:
8. Are you willing to accept Scheme
Certificate in lieu of withdrawal benefits?
(a) Yes (b) No X
9. Particulars of Family (Spouse, Children or Nominee)
Name Date of Birth Relationship
with the member
Name of the
guardian of minor
(a) Family member/(s)
(b) Nominee
10 In case of death of member after attaining the age of 28 year without filling the claim:
(a) Date of death of the member :
(b) Name of the Claimant(s)/and
Relationship with the member
: NA
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 column No.7
(b) Account payee cheque sent direct for credit to my
Savings Bank A/c..
S.B. Account No
(Attach cancelled cheque copy)
Name of the Bank (in Block Letters
Branch (in Block Letters
Full postal address of the Branch (in Block Letters)
(attach cancelled cheque copy )
IFSC code :
12 Are you availing pension under
EPS 1995? If so indicate
PPO No. _____________ By who issued: ________________
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date: Signature/Left hand thumb impression of the Member/Claimant(s)
ADVANCE STAMPED RECEIPT
(To be furnished only in case of 11 (b) above)
Received a sum of Rs.__________________________(Rupees ___________________________________
_____________________only) from Regional P. F. Commissioner Officer in-charge of Sub-Regional Office
__________________ by depositing in savings bank A/c towards the settlement of my Pension Fund account
The space should be left blank which shall be filled by this Office.
Affix
revenue
stamp
Signature/Left hand thumb impression of the member on the 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 furnished under.
(Form 3A/7(EPS) enclosed for the period for which is not sent to employees Provident Fund Office).
Date of Joining :
Wages ( Basic D.A.) as on
15-11-95 (if applicable)
Wages on the date of exit
Year Month Date
Period of non contributory service :
Date Signature of Employer / Authorized Official with Rubber Stamp
(FOR THE USE IN OF COMMISSIONERS OFFICE)
(Under Rs.P.L. M.O./Cheque..
Posses for payment for Rs... (Rupees...only)
M.O .Commission (if any) Rs...net amount to be paid by M.O...towards withdrawal
benefit.
D.A. S.S. A.A.O
(FOR USE IN CASH SECTION)
Paid by inclusion in cheque No...datevide Cash Book
(Bank) Account No.10 Debit No
D.A. S.S. AC (Cash)
Fir issue of S.S.IDS is enclosed.
D.A. S.S. 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. APFC (Pension)
