*EMP ID:-**

FORM 10 C PENSION
*Mobile No.

Group No. _____________

At ____________________
Serial No. ______________
Inward No. _____________
For Office Use Only

EMPLOYEES PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR
CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Pls. read the instructions before filling up this form )
1. a)

Name of the member

(In Block Letters)
b) Name of the claimant
(Same as above)

_____________________________________________
_____________________________________________

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

3. a)
b)

Fathers Name

_____________________________________________

Husbands Name
(if applicable)

_____________________________________________

ICICI BANK LTD.

4. Name & Address of the

Factory / Establishment in
Which the member was
last employed
5. Code No. & Account No

ICICI Bank Tower, Bandra-Kurla Complex,

Bandra (East), Mumbai 400 051.

MH / 18796 /

6. Reason for leaving service &

_____________________________________________

* Date of Leaving (DD-MM-YYYY)

_____________________________________________
7.

Shri / Smt / Kumari

_____________________________________________

S/o, W/o, D/o

_____________________________________________
Full Postal Address (In Block Letters)
H.No./R.No./Building name
_____________________________________________
Street No./Area/PO

_____________________________________________

Teh/District

_____________________________________________

State & Pin Code Number

8. Are you willing to accept Scheme

_____________________________________________

Certificate in lien of withdrawal benefit

Yes

No

9. Particulars of Family (Spouse, Childrens & Nominees)

Name
(a)

Date Of
Birth

Relationship with
Member

Name of the Guardian of

minor

Family
Member

(b)

Nomine
e

10. 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 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 me

N/A

S.B Account No.

_____________________________________________

Name of the Bank (In Block Letters)

_____________________________________________

Name of the Branch

_____________________________________________
(Mandatory to attach a cancelled cheque along with the form)
Full Address of the Branch as per cheque.
R.No./Building name
_____________________________________________
(In Block Letters)
Street No./Area/PO
_____________________________________________
Teh/District

_____________________________________________

State & Pin Code Number

_____________________________________________

12. Are you availing pension under EPS-95?

If so indicate :
PPO No._________________ By Whom Issue________________

CERTIFIED THAT THE PARTICULARS MENTIONED ARE TRUE TO THE BEST OF MY KNOWLEDGE
(X)
Date: _________________

Signature or Left Hand

Thumb impression of the
Member / Claimant

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 towards the settlement of my Pension Fund Account.

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

Re.1/Revenue
Stamp
(X) Signature or Left hand thumb impression of
the member on the stamp

Certified that the particulars of the members given are correct and the member has signed / thumb
impressed before me.
The details of wages and the 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 the employees 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 service
Year / Month __________________ days ______________
Date: _________________________
Signature of the Employer /
Authorised Official

MH / 18796 /
(FOR THE USE OF COMMISSIONERS 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. ___________________ vide cash
book (Bank) Account No.10 Debit item No. ________________________________

S.S.

A.C. (Cash)

For issue of Scheme Certificate input data sheet is enclosed

C.C.

S.S.

A.A.O.

A.P.F.C(A/cs)

(FOR USE IN PENSION SECTION)

C.C.

Scheme Certificate bearing the control No. _______________ issued on _______ and entered in
the Scheme Certificate Control RegisterS.S.
A.A.O.
A.P.F.C (PENSION)

Steps for filling Pension Withdrawal form

Mention your Employee Code & Mobile Number 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.7

Point no.11(b) Compulsory, please mention the complete Saving Bank details

Please provide ORIGINAL CANCELLED CHEQUE. If MICR code is

not mentioned on the cheque then please also attach Photocopy of Front
Page of Bank Pass Book OR Latest Bank Statement duly attested by Bank
Authority along with the Pension withdrawal form pertaining to the Bank account
number mentioned on point no. 11(b), DO NOT WRITE SALARY ACCOUNT NO.
AS IT GETS FREEZED/CLOSED AFTER THREE MONTHS.

1) Joint Saving Bank Account not acceptable / account should be in

single name of member,
2) The Cheque must bear MICR/RTGS/NEFT/IFSC Code or else the
same would be rejected.

Signature on bottom of the Page 2. Fix revenue stamp & sign across on Page 3
& keep all the details blank

Page 4 please keep it blank

Address for sending the pension withdrawal form:

PF Section - Payroll Team

ICICI BANK LTD
Trans Trade Centre,
5th Floor, Near Floral
Deck Plaza, MIDC,
Near Seepz, Andheri ( E )
Mumbai 400 093