1

FORM

10 - C

PENSION
Group No : ___________________
At

: ___________________

Serial No. : __________________

Inward No. :___________________
(For Office use only)

EMPLOYEES PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENTION SCHEME, 1995
FOR CLAIMING WITHDRAWAL 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 Name

: __________________________________________________________________

b) Husband Name
(If Applicable)

: __________________________________________________________________

4. Name and Address of the __________________________________________________________________

Factory / Establishment
In which the member

__________________________________________________________________
: __________________________________________________________________

Was last employed

__________________________________________________________________
__________________________________________________________________

5.

Code No. & Account No. :

Region / SRO Code :

Estt. Code No.

A/c No.
:
6. Reason for Leaving Service : ________________________________________________________________
&
Date of Leaving
: ________________________________________________________________
7. Full Postal Address ( In Block Letters ) Shri/ Smt/ Kumari : ________________________________________
S/o, W/o, D/o
_____________________________________________________________________
__________________________________________________PIN:_______________
.

M/s. ARP Consulting & Solutions

www.arpconsulting.in

FORM 10- C PENSION

8. Are you willing to accept Scheme Certificate:
Yes:
In lien of withdrawal benefit
9. Particulars of Family (Spouse, Children & Nominee ) :
Name

Date of Birth Relationship with Member

No. :

Name of the Guardian of Minor

a) Family
Member

b) Nominee

10. In case of Death of Member after attaining the age of 58 years without filling the Claim:a) Date of Death of member
: _______________________________________________________
b) Name of the Claimant
: ________________________________________________________
And
Relationship with the Member: _______________________________________________________

11. MODE OF REMITTANCE (PUT A, TICK IN THE BOX AGAINST THE OPTED)
a) By Postal Money Order at my Cost to the Address given against Item No. 7

12.

::

b) By Account Payee Cheque sent direct for Credit to my S. B. A/c ( Scheduled Bank):
S. B. Account No. : ____________________________________
Name of the Bank : ________________________________________________________________
(In Block Letter)
Branch
(In Block Letter) : ________________________________________________________________
Full Address of
________________________________________________________________
The Branch
: ________________________________________________________________
(In Block Letter)
Are your availing pension under EPS -95 ?
If so, indicate : PPO No. ____________________________________________________________
By whom issued :____________________________________________________
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date : __________________________
Signature or Left Hand Thumb
impression of the Member / Claimant

M/s. ARP Consulting & Solutions

www.arpconsulting.in

FORM 10 C PENSION
ADVANCE STAMPED RECIEPT

(To be furnished only in Case of (b) above)

Received a sum of Rs. ______________________ (Rupees___________________________
________________________________only) from 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 Account.
(The space should be left shall be Filled by Regional Provident Fund Commissioner / Officer-in-charge)

Rs. 1/Revenue
Stamp
______________________________________
Signature or Left Hand Thump Impression
of the Member on the Stamp

Certified that the Particulars of the Members given are Correct and the member has Signed / Thump
Impressed before me.
The Details of Wages and Period of Non- Contributory Service of the member under:(Form 3A/7 [EPS] enclosed for the period for which it was not sent to Employees Provident Fund Office.)
Wages (Basic + D. A.) as on 15.11.95
(if applicable)
:_________________________________________________________
Wages as on the Date of Exit

:_________________________________________________________

Period of Non Contributory Service:

Year / Month_________________________________Days_______________________________________

Date :.
Signature of the Employer / Authorized Official

With Designation & Seal

M/s. ARP Consulting & Solutions

www.arpconsulting.in

FORM 10 C PENSION

( FOR THE USE OF COMMISSIONERS OFFICE )

Under Rs. _____________________________________________ P. I. No.___________________________________
M. O. / Cheque
Passes for Payment for Rs.____________________________________( in Words )_____________________
_____________________________________________________________________________________________________
M. O. Commission (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.______________________________________
Wide 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 .
A. P. F. C. (A/c s)
(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 .

M/s. ARP Consulting & Solutions

www.arpconsulting.in

___________________
A. P. F. C. (A/c s)