8/12/2019 Pf Withdrawl Forms 10c

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Mobile: 9611786747Mobile: 9611786747Mobile: 9611786747Mobile: 9611786747

2222 4444 1111 1111 8888 0000

Serial No.

For Office Use Only

In Words No.

Form No.10 C (E.P.S)Form No.10 C (E.P.S)Form No.10 C (E.P.S)Form No.10 C (E.P.S)

[Withdrawl Benefit][Withdrawl Benefit][Withdrawl Benefit][Withdrawl Benefit]

2. Date of Birth

EMPLOYEES' PENSION SCHEME, 1995EMPLOYEES' PENSION SCHEME, 1995EMPLOYEES' PENSION SCHEME, 1995EMPLOYEES' PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,1995FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,1995FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,1995FORM TO BE USED BY A MEMBER OF THE EMPLOYEES' PENSION SCHEME,1995

FOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATEFOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATEFOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATEFOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATE

1. a) Name of the member (In Block Letters) Karunakaran Y NKarunakaran Y NKarunakaran Y NKarunakaran Y N

b) Name of the Claimant (s)

'

Region/SRO Code /

. a at er s ame arayanaarayanaarayanaarayana

b) Husband's Name (If applicable) NOT APPLICABLENOT APPLICABLENOT APPLICABLENOT APPLICABLE

4. Name & Address of the Establishment

in which, the member was last employed

5. Code No. & Account No.

Estt.Code No. A/c No.

6. Reason for leaving service Personal ProblemPersonal ProblemPersonal ProblemPersonal Problem

& Date of leaving 1-Feb-20121-Feb-20121-Feb-20121-Feb-2012

7. Full Postal Address (In Block Letters)

Shri/Smt/Kumari Karunakaran Y NKarunakaran Y NKarunakaran Y NKarunakaran Y N

S/o, W/o, D/o Narayana YNarayana YNarayana YNarayana Y

# 12, ABC [Vill], BSSS [Po] UUIII [Mandal]# 12, ABC [Vill], BSSS [Po] UUIII [Mandal]# 12, ABC [Vill], BSSS [Po] UUIII [Mandal]# 12, ABC [Vill], BSSS [Po] UUIII [Mandal]

Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423Kuppam [Tq] Chittoor Dist, Andhrapradesh - 517423

8/12/2019 Pf Withdrawl Forms 10c

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(a) (b)

Name Date of Birth

(a) Family Members

NarayanaNarayanaNarayanaNarayana 03-05-195603-05-195603-05-195603-05-1956

SaraswathiSaraswathiSaraswathiSaraswathi 14-05-196014-05-196014-05-196014-05-1960

(b) Nominee

Lavanya GLavanya GLavanya GLavanya G 22-22-198022-22-198022-22-198022-22-1980

Pankaj YPankaj YPankaj YPankaj Y 20-02-20120-02-20120-02-20120-02-201

8. Are you willing to accept Scheme

Certificate in lieu of withdrawl benefits Yes No

9. Particulars of Family (Spouse & Children & Nominee)

Relationship with member Name of guardian of minor

FATHERFATHERFATHERFATHER ----

MOTHERMOTHERMOTHERMOTHER ----

WifeWifeWifeWife ----

----SonSonSonSon

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 ApplicableNot ApplicableNot ApplicableNot Applicable

If so indicate: PPO No. By whom issued

(b) Name of the Claimant(s) / and relationship with the members :::: Not ApplicableNot ApplicableNot ApplicableNot 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. 6400000000000640000000000064000000000006400000000000

Name of the Bank (In Block Letters) STATE BANK OF MYSORESTATE BANK OF MYSORESTATE BANK OF MYSORESTATE BANK OF MYSORE

Branch (In Block Letters) BANASWADIBANASWADIBANASWADIBANASWADI

Full Address of the Bank KR ROAD,KR ROAD,KR ROAD,KR ROAD,

Thumb Impression of the

(In Block Letters) BANGALORE - 24BANGALORE - 24BANGALORE - 24BANGALORE - 24

12. Are you availing pension under EPS-95? :::: No No No No

- -- -- -- -

Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGECertified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGECertified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGECertified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Signature or left Hand

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(FOR THE USE OF COMMISSIONER'S OFFICE)(FOR THE USE OF COMMISSIONER'S OFFICE)(FOR THE USE OF COMMISSIONER'S OFFICE)(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.HD.HD.HD.H S.SS.SS.SS.S A.A.OA.A.OA.A.OA.A.O

(FOR USE IN CASH SECTION)(FOR USE IN CASH SECTION)(FOR USE IN CASH SECTION)(FOR USE IN CASH SECTION)

Paid by inclusion in cheque No._________________ Dt_________________vide cash Book(Bank) Account

No. 10 Debit item No.__________________________

D.HD.HD.HD.H S.SS.SS.SS.S AC(A/cs)AC(A/cs)AC(A/cs)AC(A/cs)

For issue if S.S;. IDS is enclosed.

D.HD.HD.HD.H S.SS.SS.SS.S A.A.O/APFC (A/cs)A.A.O/APFC (A/cs)A.A.O/APFC (A/cs)A.A.O/APFC (A/cs)

APFC (PENSION)APFC (PENSION)APFC (PENSION)APFC (PENSION)

(FOR USE IN PENSION SECTION)(FOR USE IN PENSION SECTION)(FOR USE IN PENSION SECTION)(FOR USE IN PENSION SECTION)

Scheme Certificate bearing the Control No._________________ Issued on _______________________and

entered in the Scheme Certificate Control Register-

D.HD.HD.HD.H S.SS.SS.SS.S A.A.OA.A.OA.A.OA.A.O