eksckby la-@ Mobile Number

1 Form 10C ( ) Page 1 of 4 eksckby la-@ Mobile Number dsoy dk;kZYk; ds iz;ksxkFkZ @ For Office Use Only nkok la[;k@Clam .. fudklh ifjYkkHk@;kstuk ds nkos gsrq iz;ksx fd;k tkus okyk izi= 10 lh FORM 10C FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE deZpkjh isa ku ;kstuk] 1995 EMPLOYEES PENSION SCHEME, 1995 izi= Hkjus ls igys funsZ kksa dks i<sa+@(Read the instructions before filing up this form) ;fn lnL;rk 180 fnu xSj va knk;h lsok dks NksM+ dj ] ls de dh gS rks izR; ykHk ns; ugh gSaA WITHDRAWAL BENEFIT IS NOT ADMISSIBLE IF MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRIBUTING PERIOD 1.

2 D lnL; dk uke Li V v{kjksa esa @ Name of the Member (In Block Letters): _____ [k nkosnkj dk uke Name of the claimant (s): _____ 2. tUefrfFk@Date of Birth (dd/mm/yyyy) 3. firk dk uke /Father s Name_____ ifr dk uke Husband s Name (If applicable)_____ 4. LFkkiuk dk uke o irk ftlesa lnL; var esa fu;ksftr FkkA@ _____ Name & Address of the Establishment in which, _____ the member was last employed 5.]}

3 DksM la- rFkk [kkrk la- {ks=@ dk dksM LFkkiuk dh dksM la- [kkrk la- Code No. & Account No. Region/Off Code Estt. Code No. A/c No. 5A) dk;kZjaHk frfFk@Date of Joining the Estt. _____ 6. lsok NksM+us dk rFkk lsok NksM+us dh frfFk _____ Reason for leaving service & Date of Leaving _____ 7.]]}

4 Iwjk irk Li V v{kjksa esa Full Address (In Block Letters) _____ Jh@Jherh@ /Smt. /Km. _____ iq=@iRuh@iq=h@S/o, W/o, @Adress _____ _____ fiu/PIN _____ # lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fu kku # fu;ksDrk ds gLrk{kj /Employer s Signature Signature or Left / Right hand thumb impression of the member Form 10C ( ) Page 2 of 4 8.}}}

5 D;k vki fudklh ifjYkkHk ds LFkku ij ;kstuk gkWa Yes ugha No Lohdkj djus ds fy, rS;kj gSaA Are you willing to accept Scheme Certificate in lieu of withdrawal benefits ;fn lnL;rk 180 fnu xSj va knk;h lsok dks NksM+ dj ] ls de dh gS rks izR; ykHk ns; ugh gSaA Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service.

6 9. ifjokj dk ifr@iRuh rFkk cPps rFkk ukfefr Particulars of Family (Spouse & Children & Nominee) (flQZ ;kstuk i= ds fodYi ds fy,@applicable only for Scheme Certificate option) uke tUe frfFk lnL; ds lkFk laca/k ukckfyd ds vfoHkkod dk uke Name Date of Birth Relationship with Member Name of the guardian of minor d ifjokj ds lnL.

7 (a) Family members [k ukfefr (b) Nomine 10. fcuk nkok fn, 58 o kZ dh vk;q izkIr djus ds ckn lnL; dh e`R;q gksus ij] %& In case of death of members after attaining the age of 58 years without filling the claim:- d lnL; dh e`R;q dh frfFk@Date of death of the member [k nkosnkjks ds uke@rFkk lnL; ls mldk laca/k@Name of the Claminant(s)/and relationship with the member 11. /kuizs dk ek/;e fodfYir fof/k ds vuqlkj lacaf/kr dks Vd esa fVd djsa Mode of remittance (put a tick in the box against the one opted) d en la- 7 esa fn, irs ij esjh ykxr ij Mkd euhvkMZj }kjk By postal money order at my cost to the address given against item : [k eq>s lwfpr djrs gq, esjs cpr [kkrk la- vuqlwfpr cSad@Mkd?]]]

8 Kj esa js[kfdar psd@ bysDV kWfud ek/;e ls vknkrk [kkrk lh/ks Hkstk tk,@ (b) By account payees cheque/ electronic mode sent Directly for credit to my A/C (Scheduled Bank ) under intimation to me. cpr CkSad [kkrk Account No. : _____ cSad dk uke Li V v{kjksa esa@Name of the Bank (In Block Letters) : _____ kk[kk Li V v{kjksa esa @Branch (In Block Letters) : _____ vkbZ-,Q-,l-- dksM@ IFS Code : _____ kk[kk dk iwjk irk Li V v{kjksa esa /Full address of the Branch (In Block Letters).]]]]]}}}

9 _____ (vius cSad [kkrs ds [kkyh@j pSd dh ,d izfr layXu djsa Please attach a copy of cancelled/blank Cheque) _____ 12. D;k vki d-isa- ;ks- 95 ds rgr isa ku izkIr dj jgsa gSa \ Are you availing pension under EPS-95 \ gka@Yes ugha@No ;fn gkWa] rks bafxr djsa ih-ih-vks- la- fdlds }kjk tkjh If yes, indicate PPO By whom fd;k tkrk gS fd esajs vf/kdre Kku ds vuqlkj lR.]

10 GSa@ Certified that the particulars are true to the best of my knowledge lnL;@nkosnkj ds gLrk{kj vFkok ck,a gkFk ds vWaxwBs dk fu kku fnukad Signature or left Hand Thumb impression of the Member/Claimant Date .. # fu;ksDrk ds gLrk{kj /Employer s Signature Form 10C ( ) Page 3 of 4 vfxze izkfIr jlhn Advance Stamped Receipt dsoy ij [k ds ekeys esa gh izLrqr fd;k tk, [To be furnished only in case of (b) above] isa ku fuf/k [kkrs ds fuiVku Lo:i {ks=h; Hkfo ; fuf/k vk;qDr@mi dk;kZy.]]}}}