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EPS 10C Scheme Certificate Form

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, bank account information, and family details. If the member has passed away, it asks for the date and name of the claimant. The form must be certified by the member or claimant and includes sections for processing the payment or issuing a scheme certificate.

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ytduyyuli yufyuf
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481 views

EPS 10C Scheme Certificate Form

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, bank account information, and family details. If the member has passed away, it asks for the date and name of the claimant. The form must be certified by the member or claimant and includes sections for processing the payment or issuing a scheme certificate.

Uploaded by

ytduyyuli yufyuf
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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)

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