EMPLOYEES PENSION SCHEME, 1995 Form 10-C (EPS) Form for claiming withdrawal benefit / Scheme Certificate

(Read INSTRUCTIONS before filling in this form)

1 (a) Name of the Member: ASHOK KUMAR MANGALORE (In Block Letter) (b) Name of the claimant(s): 2 Date of Birth: 01/06/1971 3 Marital Status: MARRIED 4 (a)Fathers Name: L.S. MANGALORE (b) Husbands Name: (if applicable) 5 Name & address of the Establishment in which, the member was last employed:
CUBIC TRANSPORTATION SYSTEMS INDIA PRIVATE LTD., H-08, LEVEL 1, MODULE 1, L T PHOENIX INFOPARKS PVT. SEZ HITECH CITY 2, GACHIBOWLI, HYDERABAD 500081

Region/SRO Code Esstt. Code No. AP/HYD/63640 A/c. No. 6 Establishment Code No.: AP/HYD/63640 & Account No.: AP/HYD/63640/26 7 Reason for leaving service & Date of leaving: RESINGATION, 31 JUL 2012 8 Full Postal Address (In Block Letters) Shri/Smt./Kum./S/o / W/o / D/o
Ashok Mangalore, 301, II B BLOCK, SMR VINAY ACROPOLIS, WHITEFIELDS, KONDAPUR, HYDERABAD - 500081 PIN: 500081

9 Are you willing to accept Scheme Certificate in lieu of withdrawal benefits? (a) Yes ( ) (b) No ( ) 10 Particulars of Family (Spouse & Children & Nominee) Name Date of Birth Relationship with Member Name of the Guardian of Minor Savita 28/08/177 Spouse Chinmay 23/11/2005 Son Savita (A) Family Member: Savita (B) Nominee: Savita 11 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(s) / and relationship with the members _______________ 12 MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ONE OPTED)

(a) Bypostal money order at my cost to the address given against Item No. 7 ( ) (b) Account payee cheque sent direct for credit to my SB A/c. (Scheduled / Co. Operative Bank/Post) Under intimation to me. ( )
S.B. Account No.: 05451050153253 Name of the Branch: HDFC BANK LTD., Branch: MADHAPUR Full address of the branch:
GR FLOOR, CYBER HEIGHTS PLOT NO 30 ROHINI LAYOUT, OPP CYBER TOWERS, HITEC CITY, MADHAPUR HYDERABAD 500081 ANDHRA PRADESH

13 Are you 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: 25 October 2012
ASHOK MANGALORE

Signature or left Hand Thumb impression of the Member/Claiment(s) ADVANCE STAMPED RECEIPT (To be furnished only in case of 12(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 blank which shall be filled by Regional Provident Fund Commissioner / Officerin Charge)
Affix Re.1.00 Revenue Stamp

ASHOK MANGALORE

Signature & left hand thumb impression of the member on the stamp

Certified that the particulars of the member 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 3A/7 (EPS) enclosed for the period for which it was not sent to Employees Provident Fund Office.) Wages (Basic + D.A.) as 15-11-95(if applicable): Wages as on the date of exit: Rs. 75,000.00 Period of non contributory Service Year/Month/No. of Days: Nil

Date: 25 October 2012

Kishan Rao K

Signature of Employer / Authorised Offical

(FOR THE USE OF COMMISSIONERS OFFICE) (Under Rs. _________________________ P.I. No. ________________________ ___________________________________M.O. / Cheque / Passed for payment for Rs. _____________________________ (In Words Rupees) ______________ _________________________________________ M.O. Commission (if any) _______________________ / net amount to be paid by M.O. ____________________________________towards withdrawal benefit. D.H. S.S. (FOR USE IN CASE SECTION) Paid by inclusion in Cheque No. ________________ Dt. _________________ vide cash Book (Bank) Account No. 10 Debit Item No. ___________________ D.H. For issue if S.S,: IDS is enclosed. S.S. AC(A/CS) A.A.O.

D.H.

S.S. (FOR USE IN PENSION SECTION)

APFC(A/cs)

Scheme Certificate bearing the Control No. ______________ Date ___________ Issued on and end entered in the Scheme Certificate Control Register. D.H. S.S A.A.O. APFC(PENSION)