I have Attached EPF Form 19 & 10-C Format
Mobile: 98427 98427 | Serial No. | ||||||||||||||||||||||
For Office Use Only | |||||||||||||||||||||||
In Words No. | |||||||||||||||||||||||
Form No.10 C (E.P.S) | |||||||||||||||||||||||
[Withdrawl Benefit] | |||||||||||||||||||||||
EMPLOYEES’ PENSION SCHEME, 1995 | |||||||||||||||||||||||
FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME,1995 | |||||||||||||||||||||||
FOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATE | |||||||||||||||||||||||
1. a) Name of the member (In Block Letters) | ABC | ||||||||||||||||||||||
b) Name of the Claimant (s) | ABC | ||||||||||||||||||||||
2. Date of Birth | 0 | 5 | 0 | 8 | 9 | 2 | |||||||||||||||||
3. a) Father’s Name | XYZ | ||||||||||||||||||||||
b) Husband’s Name (If applicable) | NOT APPLICABLE | ||||||||||||||||||||||
4. Name & Address of the Establishment | ABC COMPANY INDIA PVT LTD., | ||||||||||||||||||||||
in which, the member was last employed | X-18, 6th Cross Cut Road, Perundurai, Erode – 52. | ||||||||||||||||||||||
5. Code No. & Account No. | Region/SRO Code | TN | / | SL | |||||||||||||||||||
Estt.Code No. | A/c No. | ||||||||||||||||||||||
XXXXX | YYY | ||||||||||||||||||||||
6. Reason for leaving service | CESSATION (SHORT SERVICE) | ||||||||||||||||||||||
& Date of leaving | 1-Feb-2012 | ||||||||||||||||||||||
7. Full Postal Address (In Block Letters) | |||||||||||||||||||||||
Shri/Smt/Kumari | ABC | ||||||||||||||||||||||
S/o, W/o, D/o | XYZ | ||||||||||||||||||||||
1/12 – ANTI VALASA, MAKKUVA POST & TALUK, | |||||||||||||||||||||||
Vizianagaram, A.P.. PIN: 535 547 | |||||||||||||||||||||||
8. Are you willing to accept Scheme | (a) | (b) | |||||||||||||||||||||
Certificate in lieu of withdrawl benefits | Yes | No | √ | ||||||||||||||||||||
9. Particulars of Family (Spouse & Children & Nominee) | |||||||||||||||||||||||
Name | Date of Birth | Relationship with member | Name of guardian of minor | ||||||||||||||||||||
(a) Family Members | |||||||||||||||||||||||
PAPARAO | 1966 | FATHER | – | ||||||||||||||||||||
PARVATHI | 1976 | MOTHER | – | ||||||||||||||||||||
(b) Nominee | |||||||||||||||||||||||
PAPARAO | 1966 | FATHER | – | ||||||||||||||||||||
PARVATHI | 1976 | MOTHER | – | ||||||||||||||||||||
10. In case of death of member after attaining the age of 58 years without filing the claim :- | |||||||||||||||||||||||
(a) Date of death of the member : | Not Applicable | ||||||||||||||||||||||
(b) Name of the Claimant(s) / and relationship with the members : | Not Applicable | ||||||||||||||||||||||
11. MODE FOR REMITTANCE [PUT A TICK IN THE BOX AGAINST THE ONE OPTED] | |||||||||||||||||||||||
(a) By postal money order at my cost to address given against item No.7 | |||||||||||||||||||||||
(b) Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation | |||||||||||||||||||||||
to me | √ | ||||||||||||||||||||||
S.B Account No. | 1 | ||||||||||||||||||||||
Name of the Bank (In Block Letters) | STATE BANK OF INDIA | ||||||||||||||||||||||
Branch (In Block Letters) | PERUNDURAI | ||||||||||||||||||||||
Full Address of the Bank | KOVAI MAIN | ||||||||||||||||||||||
(In Block Letters) | PERUNDURAI | ||||||||||||||||||||||
12. Are you availing pension under EPS-95? : | No | ||||||||||||||||||||||
If so indicate: | PPO No. | By whom issued | |||||||||||||||||||||
Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE | |||||||||||||||||||||||
Signature or left Hand | |||||||||||||||||||||||
Thumb Impression of the | |||||||||||||||||||||||
Date: 02-04-2012 | Member / Claimant(s) | ||||||||||||||||||||||
ADVANCE STAMPED RECEIPT | |||||||||||||||||||||||
[To be furnished only in case of (b) above] | |||||||||||||||||||||||
Received a sum of Rs._________________ (Rupees__________________________________________________ | |||||||||||||||||||||||
only from the Regional Provident Fund Commissioner / Officer-in charge of Sub-Regional | |||||||||||||||||||||||
Office _____________________________ | |||||||||||||||||||||||
by deposit in my savings bank A/c towards the settlement of my Pension Fund Accounts | |||||||||||||||||||||||
(The space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer-in- | |||||||||||||||||||||||
charge) | |||||||||||||||||||||||
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Rs.1/- Revenue Stamp |
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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 as under :- | |||||||||||||||||||||||
Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employee’s Provident Fund Office) | |||||||||||||||||||||||
Wages (Basic+DA) as on 15.11.1995 (if applicable) : | Not Applicable | ||||||||||||||||||||||
Wages as on the date of exit : | Rs.100.00 per day | ||||||||||||||||||||||
Period of non contributory Service | |||||||||||||||||||||||
Year / Month | No. of Days | ||||||||||||||||||||||
2011 / 10 | 17.0 | ||||||||||||||||||||||
2011 / 11 | 4.0 | ||||||||||||||||||||||
2011 / 12 | 2.0 | ||||||||||||||||||||||
2012 / 01 | 19.0 | ||||||||||||||||||||||
TOTAL | 42.0 | ||||||||||||||||||||||
Signature of Employer/ | |||||||||||||||||||||||
Date: 04-02-2012 | authorised official | ||||||||||||||||||||||
(FOR THE USE OF COMMISSIONER’S OFFICE) | |||||||||||||||||||||||
(Under Rs.____________________________________________________________________________________ | |||||||||||||||||||||||
P.I No._________________________________ M.O./Cheque | |||||||||||||||||||||||
Passed for payment Rs.___________________________ (in words)___________________ | |||||||||||||||||||||||
M.O Commission (if any)_________________ Net amount to be paid by M.O_______________________________ | |||||||||||||||||||||||
____________________________________________________________________________________________ | |||||||||||||||||||||||
towards withdrawl benefit. | |||||||||||||||||||||||
D.H | 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.__________________________ | |||||||||||||||||||||||
D.H | S.S | AC(A/cs) | |||||||||||||||||||||
For issue if S.S;. IDS is enclosed. | |||||||||||||||||||||||
D.H | 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- | |||||||||||||||||||||||
D.H | S.S | A.A.O | |||||||||||||||||||||
APFC (PENSION)
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