I

1 ~W'/MobileNumber{IRt;r~~ ~/For OfficeUse Only1U1IT~ .. ~iftFfq~ ~104l(iI;:lf:~.)APPLICATIONFORMONTHLYPEN SIONFORM-IO-D( )~mt~.11l96(EMPLOYEES'PENSIONSCHEME,1995 )~ IN'JIcm ~ if 1I1f ~~/(ReadINSTRUCTIONS beforefillingIn this Form) 'et; &m WrI<PT ~~mn t ?By whomthe Pensionis claimed?2. GT<Il~ 'l{ ~<PT W/iRTypeof PensionClaimed(q) \jfi'<J~/3mj/Dateof Birth/Age(dd/rnmlyyyy)11111111113.(C/i) ~</iT "'fl1f~'lI1l'Rf1l) Member'sName(1nBlockLetters)(<if) 1Wr/ SEX: T) ~~/MaritalStatus@") furr/'lFct</iT "lJ1'I/Father's/Husband' "If. Wffi"ffi:lm/ >PT "' ~<PT ffiCIT" ' ~</iT 'Wl" q ' IT v ~&'<f-l( ~ Addressof the Establishmentin whichthe memberwas last ~~ ~ / DateofleavingService(dd/mmlyyyy):1 I 111 111 1 I 1~--~~==~==~~ ~</iT <IiR"T/ Reasonof leavingService'l?! ~~ 'lOT/ Addressfor communication(a)In case ofreducedpension(opteddatefor commencementof pension.}}

2 ~/Datelffl\"/Monthqrf,lYear~/~~ "iffi'llffi/Signatureof memberlapplicant~et; "iffi'llffi/Signatureof Employee'sFormlOD ( )Page10f69. # -mtet; 1/3'lflT et; tfl~IJlqCj)~OIi!jf fi't<I;(;qOptionfor commutationof 1/3 of Pension~1f;<!'IINifflCj)~olet; ~ ~~ '1<lTm<IT-mt"CI>T~~(If optionis for lesserCommutationindicatethe quantum)~ IY es"'lift INo,-------,IDIf Yes, Quantum10.# 'i'l\'\ <t'l ~~ fi't<I;(;q[(./)~WTflf]Optionfor Returnof a tick (./)"!1ft ~ <IT 3 ItRfi't<I;(;q<t'l tffiGq;'r <:Wl1If yes,indicateyourchoiceof alternative~ /Yes"'lift /NoCJCJ[!][2Jw11. # 'i'l\'\ <t'l "Cf"Ttffit~ "fIfimmfctff"CI>T~ ~cm IMentionyourNomineefor Returnof Capital~/NamemlRelation'lOl/AddressI I I I I I I Iw<I~/Dateof Birth)(dd/mmlyyyy)# ~ ~~ "" tm;r ~ fit; ~"if ~ ~/Notapplicableif pensionstartdateis on or ~<PT f<tcRuT/Particularsof Family~.]

3 <to~\iI""1~/~~<p~'#li~~et; ~<: ~<PT~~et;"Wl"mGuardianNameRelationshipwithMember(1)(2)(3)(4)(5)(6)~:~~ ~~tf fc/q;ffi7r~ <IT "fT1{et; ~ 'arn<ffi'GWlINote:If any childis physicallyhandicapped,pleaseindicate"DISABLED" ~<t'l ~ <t'l ~~ ~ m) IDateof deathof Member(ifapplicable)1 1 I I I I I I I14~~ ~ ffi' <PT f<tcRuT/Detailsof BankAccountsOpened1~<PT "fT1{/Nameof the Bankmm<PT "fT1{I NameoftheBranch23'l'l 6 ICfil:jffi'1 FullPostalAddress~q;);sI Pin Code(~~-am ~ ~/~'tII;iIt1llI!'lIftt~eR Pleaseattacha copyof cancelled/blankCheque)# ~/~rf; ~/Signatureof ; ~/Signatureof EmployerFormIOD( )Page2 of6'fi. ~.~/~1'ffl"'Wf/" ;-mm ~. /SI NoNameofClaimant(s)SavingBankAccountNumber14..A (c!i) ~ GT<ITfcIrn\"'Ilf>rff<ZIfcltr"[RT~fclxrr 7J<IT ~ m ~~(a) If the claimis preferredby nominee, ,(1)' ,--\(2) ~ ~ct; ~~/RelationshipwithdeceasedMember15.]}}}

4 ~Wll"f1'ffl"flm"ur~ Cffl ~tr~ct; tjffim ~ cfflt m}Detailof SchemeCertificatealreadyinPossessionof the Member,ifany~~m'<f ~ " ISchemeCertificatereceived& enclosedm'<f -;ffi) / Not receivedDDD"ffil!~Not Applicable~"SIT'<!t en ~/ifReceived,Indicate:~.SchemeCertificat eControlNo'fi. ~.SI NoAuthoritywhoissuedthe SchemeCertificate16.~ ~q;. if. m., 1995ct; 3Rf1fQ~ \iIT 1(jft~Ifpensionis ,1995l\ \ rvr. / \3'. et. <!iT."[RT-;;ffi)Issuedby RO/SRO17.~~(~et;~~/Documentsenclosed(Ind icateas per the Instructions) ~fiImrvmrr~ I Certifiedthat;0)i'f ~m mwrr,1995et; ~iWf;ffil ~ W tlI am not drawingPensionunderEmployee'sPensionSche me, )~ ~tf?[ "4 ~ flm"ur~ ~ -mt t IThe particularsgivenin this applicationare true and correct~lDate~lPlace~et; ~<rn 6W <t'I 3t'!, ;ftSignatureI LeftHandThumbImpressionoftheapplicant~~ ~/SigDatureof Employer~.]]

5 F.\1I)1ft!y/~~um'Rf'GIRrt)FormIOD ( )Page3 of6(TOBE FILLEDUP BY THEEMPLOYER!AUTHORISEDOFFICEROF THEESTABLISHMENT)lIJ!IfiIRrFcmrr \lJJill~ ~ / Certifiedthat:1. ~<IiT~mlHIThe particularsof the memberare ~ ~q\\ ~~ ~ ~ 12 ~q\\ ~<liT~~ iWt~<liT~IThe particularsof Wagesand PensionContributionfor the periodof 12 monthsprecedingthe dateofleavingserviceareas under:~ ~wfi 12 ~Tj ~~ <Cl 'It ~ m 12 'Ilft;ITifj[~-31f.<rq"ill< ~ ~ ~ JlNI'l{~(in case,the wagesare not earnedfor all 12 months,the blockof 12 monthswill commencebackwardsfromthe last paydrawn)<i't~~/Wages~1llA~"" ai"mTIlt~<I>ltffiuTI ~YearMonthPension~~~tm~GW'fcontributiond ueDetailsof periodof thereis no suchperiod,indicate'Nil'~q\'t<' "lfIf/Year~q\'\<'i.~~~No. of daysAmount~3lAAcr~ q\\'It/no. of daysforwhichno wageswereearned(1)(2)(a)(4)(5)(6)(7)~: Enclosures:I.]}

6 ~-q ~ ~/Docurnenteas givenin the Instruction2.~q~uilCi1q>~~ ""flT ~ifj["If'BI/Formof descriptiveroll and specimensignature~lDate~fplace~i!\"~/~~" $ ~~ ~*ft'IIIINS ignatureof Employer!AuthorisedOfficialof the EstablishmentwithSealandDateFormIOD ( )Page4 of6~~1ffiI~~<f;~"'I~2 ~"'Ilffi1O~\iIl\[)(Tobe submittedin duplicatedin respectof eachpersoneligiblefor pension)~ -M't <fiT fc'fcRuraIR ~~ ~/~ 'lDescriptiveroll of Pensionerandhis/herSpecimenSignaturefThumbimpressionl.~<fiT "'frI{/Nameof the >.'l' 't.~ <' <fiT "'frI{/Nameof the !fa<fiT "'frI{/Father'slHusband' ~ pensioner1 .. ~ "~~ -M't) ~ qlt cmr 1{ ;ml ~ qlt ~<f; 'l.[Onlyin the caseof illiterateClaimant(Pensioner)LeftHandFingerImpression]~/THUMB~/INDEX"It2 PIT1 MIDDLE~/RINGq; ~/Place:~/Date:~/Signature~~<f;"'frI{~>ITiRNameof the AttestingAuthorityOfficialSealFonn100 ( )Page5 of6~~~~)(FOROFFICEUSEONLY)(tl'wi3Fj"1I'T /mm3Fj"1I'T)(pENSIONSECTION/ACCOUNTSSECT ION)WlTflIRI~iiImT~ ~ ~~ Tj ~~<!]]}}}}}

7 IT ~~~ ~WIfCI"'f<IRfRm7fm t 1 ~~tg 'lBIt 1 3lJqif;~~~~~)-;jh)~~tlCertifiedthat the particularsin the applicationhavebeenverifiedwiththe relevantconcerneddocuments,the claimantis InputDataSheetis placedbelowfor approval:~-9/lI1rn-3("4. tft.) 'ffiC<mm~/GTQI3lJqif;~~ ~<IR <'ft ~ tlEnteredin Form91F0rm3(PS).MasterLedgerCard!ClaimIn wardRegister~&m~~~~~-2(3lRl~tlForm2( R) enclosedalongwiththe documentsfurnishedby the Claimant.'ffi.~.~. ~ ~.~.~. ~.' (/tffi) (Pension)~/Date~/Date~IDate~IDate~"ff'!" lmsn~<t;~(FORUSEIN PENSIONPRE-AUDITCELL)~srer ~ ~ ~~ ~~~ <If.!I~<IR ~'lm ~ am -mT tJr!lT7fm t 1 ti. 3 RWft3l$Tq;'t ~&m"1hrn<IR~V!T1;[1 The Inputdatesheetverifiedwithreferenceto the applicationand the documentsenclosedand 'ffi.~.~./SSA3lj.~ ,b~. ~.' ! ~) (Pension)~/Date~/Date~/Date~/Date(/tffif lI<Rur~~ ~)(FORUSEIN PENSIONDISBURSEMENTSECTION)Tt 31.]

8 31. " ;lIi't UJRt <IR'lctft ~Dateof issueto the Bankta>Bank~lIi't ~<f1!ITmm 3!'J'WTq;'t ~UJRt <IRtt ~ ~1 Intimationsent to the Claimantand also to AccountBranchon'ffi.~.~. ~ ~.~. ~.' ! ~) (Pension)~/Date~/Date~/Date~/DateFormIOD ( )Page6 of6