af 10 Bw, FR. at) TELEPHONE NO. (Re geen fetter) EMPLOYERS’ wri 10 1 ( o. a. a. ) z EMPLOYEES (Re gees ore) : ‘CLAIMANTS é P.R.O. ~ 647 00 07 Form 10 C (EPS) GRIEVANCES = -_-647 00 25 (Supplied Free of Cost) 647 00 29 fae anid sere | onee wate a Reale jeae erafenita vain | ama tem Pare For Office use only Inward No. & Date : aatart fradttaa ator, 2¢¢5 tert Puta torn, vers ar aaah Prenat / awa earorearen gramefter wereaTaT sist (at amt) wear Fart AIST, 1995 ae oar wae are astarit er atom, 1995 % frenit ore / waite afsfeee tq em ore! (arr es A eee TT see Se) eee re See 1985 IT AN (PLOYEES' PENSION SCHEN i Read the instructions Sei ttn up this form) 1. 9) Weert are ( sae Hert) : | @) wee a (ae ant AT) a) Name of the member :- (In Block Letters) ® asterrt are @ wees c) Name of the claimant a oer atte am far Date of Birth aera wa ‘frat ar APT Father's Name fag vate are ( ory sere) vat ar ara ( af ony at) cas Husband's Name ( if applicable ) 4, seer sa semi stadt arptien aat, et ara a aT. emer ar ara a vat Barer aoe afar an fra ar | Name & Address of the Establishment inwhich, the member was last employed. ea Oss Weg eaee pai ere ae waar / 3. 8 OE Srey TE AT a Te aa en ed aT FT Ba / 3. aa PIA EF. ara &, ‘Code No. & Account No. Region / SRO Code Est. Code No. AIC No. 6, dar arevaret aera a fate sipit are er ern cea far Reason for leaving service & Date of leaving 7. ony arechy) art é gf wh / ot pi sure wat ( sae aT) at / avait / part Tr / ait / a a rT GT ( wre watt) ShJ Smt. / Kumari ‘S/o, Wio, Dio Full Postal Address ( In Block Letters) 8, frerit eraren ( fagiae atafaea ) saema asta aot amy frareit erat & BI Te oiraar wares UTE ? ‘Are you willing to accept Scheme Certificate in lieu of withdrawal benefit. ? ae ape ey ere fax ais / PIN Oo | (3H) / (CB) / (a) (4) / (bd) / CF) wa / at /yes amit / a8 / No 9, eearfarniten auatter (uct / aot, ae a arateatare aan ) afvare wr fara ( ferarfertt, wor wt aaa ) Partioulars of Family (Spouse, Children & Nominee ) a ) Fates set 3, (War weet Nome (a) Family Members Saas | Sears a [eam aera oats | aeer & are Bers lara & aiferae a aT [Date of Birth|Relationship with Member] Name of the guardian of minor 1 a 3 4 5 6 (@ arate S| ro (b)_Nominee 410, STearSt a erT IATA TATTT 3 SIT ams mer Sy A aT ST sree Incase of death of member after attaining the age of 58 years without filing the claim (31) zee appt ante (Ce) seer Hi 7 FAP (a) Date of death of member (4) seks ara a are eect ae (a) aaaren ant od weed & are en (b) Name of the Claimants) and relationship with the member;MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ONE OPTED ) (31) gate o mat free searer agar eaeht aPratscare ater - (&) Rt ert wr acitorge grat me a. 7 & ait fee my at ae (2) By postal money order at my cost othe adress given against tem No. 7 (a) Saree et reer reat ( aeges ) edhe eae wera geen eq de eae are (3) ag gfra eet ge arent ere or tee Be aay warm (safrgheg @e ) Hor ai ig tn ear ae | ‘aa (b) Account payee cheque: ‘sent direct for credit to ‘my SB Alc ( Scheduled Bank) Under intimation to me. wrt art gis | aa aa (are sere) eT (BNE se) gen de ert a. | fear areca: suri a) | aren (9 sent i) $8.8. Account No. Name of the Bank Branch ({n block letter) (in block letter ) ameter got gat (ane wert) ATTY TPT FAT (aE stent a) Full address of the Branch (in block tetter ) 12 eiant frptien han, vers samt om Pegaitaarer ore Se Sia ere? a stone Ey Td. dh ah pate omg art Sen ior war amt, %, a. 1995 3 arena dare tt oft. amie fare are anit fear ae = ‘3 OTH sore #2 ate tar fat she ae | P.P.O.No. By whom issued Are your availing pension under EPS-95 7 Iso, indicate : Sere i wren sibeitqar at silts Het sie, set waif eran Aa Store Fear sr & fs frmem 3 ara stgare att #1 CERTIFIED THAT THE PARTICULARS ARE TRUE ‘TO THE BEST OF MY KNOWLEDGE faaie / arte / Date see / ater ene see gran sare sinsarar sat eee / arden je mrarere my are os & aq? & fro Signature or ist Hand Thumb impression of the Member claimant 13 ans fafrerre wait (Sax (a) seen TATE ) str wach welt ( 2a salen (a) & fer an arr j ADVANCE STAMP RECEIPT [ 10 5 FURNISHED ONLY | a FF tora fet are Breer a7 ee arr a oa Paved suman RN ERM eMac ape/rt tet re fe Received a sum of Rs. (Rupees, only } from paper ese eee ae ts Regional Provident Fund Commissioner /Otficer in charge of Sub - Regional Ottice. Geposit in my saving Bank A/c, towards the settlement fester weet anit seer gran geen shearer ga eee Goat Feet eemtgre aT ay ere fe sts ar Pree omy Signature or let hand thumb impression of the member on the stamp.14, ‘rere aractte fecienr aaeiter sitet ane ear Area ae rari echt are / shrearay sat Fer aM. aaaren oasis a aeearen fer-ainratina (ate etsteeht ) eter ered er ata sitseret sist a / © (mfrah) gare ane. ar erent & ahah afeertrate frelt eraterarr setter art tet. rarer Fesar sara & fie ree are fae are freer wet Ee weer a AT aH ReMTAT fe / siqeT oT Z| weer St srateerit dar st staf at agit er frre fer were ae: (aa sat or ort 3/7 (wat. ) dome & ott actarit afer fait erates at af aor war) Certified thatthe particulars of the members 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 A/’7 (EPS ) enclosed for the period for which it was not sent to Employees’ Provident Fund Ottice. ) ‘aaa ( qe aaa + Here wT) | Age ( Aw + Ham eT) | Wages ( Basic + D. A.) as on Rs. ¥4.22.0% aT Pratt (omy srawara) | 15.11.95 & fea (ate ey #)}15. 11. 95 ( if applicable ) sitet atecarenn feaeiry ae [fete ferdt & fer at srgit Wages as on the date of exit Rs.: fier - shrerfr Sar erent at / ate / fee statrardt war at arafir at / are / fet Period of non contributory Service Year / Month / deys js are / aifirgs sift at feaie : aire : Date: —__ Frater / wre srfteertt & eerare Signature of Employer / Authorise: Officials with Seal. (FOR THE USE OF COMMISSIONER'S OFFICE ) (Under Rs.__P. |. No, __M. 0./ Cheque. Passed payment for Rs. ___(In words). M. 0. Commission (f any) __netamount to be paid by M. 0. _ towards withdrawal benefit ec. SS, AAO. (FOR USE IN CASH SECTION ) Paidby inclusion in cheque No__Dt.__vide cash Book (Bank) Account No.10 Debit tem No. 8.8 ‘AG (CASH) Forissue of Scheme Cetiicate, Input Data Sheets enclosed Cc, 8.8. AAO. APFC (Ales) (FOR USE IN PENSION SECTION ) ‘Scheme Cerificate bearing the control No.____Issued on __and entered in the Scheme Cartcate Contr Register, co, 8.8. AAO. ‘APFC ( PENSION)