Pension Withdrawl Form 10 C

8/3/2019 Pension Withdrawl Form 10 C

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Steps for filling Pension Withdrawal form

• Mention your Employee Code on top of the Pension Withdrawal Form

• You are requested to clearly mention all the details in BLOCK LETTERS from point

no.1 to point no.3

• Point no 4,5,6 leave it blank

• Point No.9, 10, & 12 – Please leave it blank

Point no.11 please mention the complete Bank branch address

• It is Mandatory to attach “ORIGINAL CANCELLED CHEQUE “along with the

Pension withdrawal form pertaining to any of the saving Bank account numbermentioned on point no 11 or else the form will get rejected by the Regional ProvidentFund Commissioner .

• Signature on bottom of the Page 2 where (X) is marked . Fix revenue stamp & signed

across on Page 3 & keep all the details blank

•

Page 4 please keep it blank

• Address for sending the pension withdrawal form:

o ICICI Prudential Life Insurance Company Ltd,

o Shared Services - HR Ops ( PF Team)

o Grd Floor, Vinod Silk Mills Compound, Ashok Nagar,

o Chakravarti Ashok Road, Kandivali - East, Mumbai - 400 101



EMP ID:-

FORM 10 – C PENSION

Group No._____________At _____________Serial No. _____________Inward No._____________For Office Use Only

EMPLOYEE’S PENSION SCHEME, 1995FORM TO BE USED BY A MEMBER OF THE EMPLOYEE’S PENSION 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) First name Surname

b) Name of the claimant _________________________________________First name Surname

2. Date of Birth( DD-MM-YYYY) __________________________________________

3. a) Father’s Name _________________________________________

First name Surname

b) Husband’s Name _________________________________________ (Only incase of married female)

4. Name & Address of the ICICI Prudential Life Insurance Company Ltd

Factory / Establishment in ICICI Prulife Towers, 1089, Appasaheb Marathe,Which the member was Prabhadevi, Mumbai – 400 025last employed

5. Code No. & Account No

6. Reason for leaving service & Resigned

Date of Leaving _________________________________________

7. Full Postal Address (In Block Letters) ______________________________________

House no/Room no/Bldg no______________________________________

Street No./Area/PO_______________________________________

State & Pin Code Number______________________________________

MH / BAN / 49598 /



8. Are you willing to accept SchemeCertificate in lien of withdrawal benefit Yes No

9. Particulars of Family (Spouse, Children’s & Nominees)

NameDate OfBirth

Relationship withMember

Name of the Guardian ofminor

(a) Family

Member

(b) Nominee

10. In case of death of member after attaining the age of 58 years without filling theclaim:

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 ONE OPTED)

a) By postal money order at my cost to the address given against item no. 7

b) By Account Payee cheque sent direct for credit to my S.B a/c (Scheduled Bank)Under intimation to meS.B Account No. ____________________________________(Mandatory to attach a cancelledcheque along with the form)Name of the Bank ____________________________________

(In Block Letters) ____________________________________

Branch ____________________________________

(In Block Letters) _____________________________________

Full Address of the Branch _____________________________________(In Block Letters) _____________________________________

12. Are you availing pension under EPS-95?If so indicate : PPO No._________________ By Whom Issue______________________________________________________________________________________

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date: _________________ Signature or Left Hand

____________________________ (X) Thumb impression of theMember / Claimant

X

X



ADVANCE STAMPED RECEIPT(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 to – wards the settlement of my Pension Fund Account.

(The space should be left blank which shall be filled by Regional Provident FundCommissioner / Officer – in – charge)

(X) Signature or Left hand thumb impression ofthe member on the stamp

Certified that the particulars of the members given are given are correct and themember has signed / thumb impressed before me.

The details of wages and the period of non-contributory services of the memberare as under:-(Form 3A/7 (EPS) enclosed for the period for which it was not sent to theemployee’s 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 services Year / Month _______________________ days ______________________

Date: _________________________

Signature of the Employer /Authorised Official

Re.1/-Revenue

Stamp



(FOR THE USE OF COMMISSIONER’S OFFICE)

(Under Rs.______________________________________ P.I No.________________________M. O. / Cheuqe

Passed 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. __________________ videcash book.

(Bank) Account No.10 Debit item No. ________________________________

S.S. A.C. (Cash)

For issue of Scheme Certificate input data sheet is eclosed

C.C. S.S. A.A.O. A.P.F.C(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. A.P.F.C (PENSION)

Documents

Pension Withdrawl Form 10 C