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8/18/2019 Scan10001 (2)
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Employer
Claimant
Phone
No.
Mobile
No.
orflorc
ereir
I
Serial
No.
:
urgorrb
10
-
C
(@ooreone
orpriroOuuug1)
qqrr
-
10-fr
(o.
E.
fr)
tt+g-trEffi,
FORM:10-C(EpS)
(Supplied
free of
cost)
e4glloroc
a-uGruno$$gqg
rou@rb
(e-efua.ltro{
ereir
ro$E6
GpS)
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Efl'qtdq
+
q*q
+
tdq
(q|{tr,qq
R{itr,I
For
office
use
only
(lnward
No.
& Date)
'
)
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GluetroEei'r
$uurb,
1995
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EMPLOYEES'
PENSTON
SCF|EME,
tgg,
Fom
to
ba
used
by
a
membet
of lhe
cmployecs'
Peniion
Scheme,
lggb
for
ctaiming
withdrawat
Benefit/Scheme
certiticate
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the
instrucfions
before
fllling
up thisfLrm)
GN)
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t
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eElairoruupnyrfleh
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ctaimant(s)
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Date
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pporpurnrfleir
Gluuri
Far
or
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Father's
Name
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o
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Husband's
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Name l Address
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benefit.
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Received
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----------
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(Rupees
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froi
Regional
provident
Fund
Commissioner
/ Office-in-Charge
of
Sub-Regional
office /
Sub-Accounts
office
by
deposir
in
my
saving
Bank
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settlement
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penslon
Fund
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space
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rqsfroe
Re 1/- Revenue Stamp
8/18/2019 Scan10001 (2)
http://slidepdf.com/reader/full/scan10001-2 4/4
1a.
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Cedified that the
pafticulars
of the
above
member
are
correct
and
he
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
Employees'
provident
Fund
Office)
e.o$rurb
(grlrquuenl
enpru6
+
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15.11.1995
aleing
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r
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Service
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rcncr
€
A/c
No.
Wages
(Basic
+ D.A)
as on
15.1
1.95
(lf
applicable)
Wages
as on
the
date
of
exit
Rs.
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r
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Date
:
T
Frfrrdr
er
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qrnryd
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ct6t
\rtrd.
Signature
of
Employer/
Authorised
Official
with
Seal.
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15.1 1.95
fqR
ortl
{ffiftdgififfiqr
(Under
Rs
:
(FOR
THE
USE
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OFFTCE)
P.l.No.
(in
words)
net amount
to
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M.0./Cheque.
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assed
payment
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Commission
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AO
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H
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CASH
SECTTON)
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by
inclusion
in
cheque
No. Dt.
vide
cash
Book
(8ank)Account
No.
10
Debit
item No
AC
(Cash)
S
AO
H
For
issue
of
S.C,
IDS is
enclosed with
Form
-
2
(Revised)
D.J.
APFC
(Cash)
Scheme
Certificate bearing the
control
No.
(FOR
USE
TNPENS|ON
SECTTON)
lssued on
and entered
in the
Schepe
Certificate
Control Register
DH
SS
AO
APFC
(PENS|ON)
