Forward Office Use Only Inward No. APPLICATION FOR MONTHLY PENSION FORM 10-D(EPS) EMPLOYEE'S PENSION SCHEME, 1995 (Read INSTRUCTIONS before filling in this Form) 1. By whom the pension is Claimed ? 2. Type of Pension Claimed. 3. (a) Member' Name : (In Block Letters) (b) Sex : (c) Marital Status : (d) Date of Birth/Age : (e) Parent/Spouse Name : 4. E.P.F. Account Number : RO SRO Establishment Code No. Members's Accounts No: 5. Name & Address of the establishment : in which the member was last employed 6. Date of Leaving Service : 7. Reason for leaving Service : 8. Address for communication : PIN: ______________________ 9. Option for commutation of 1/3 of Quantum: Yes No Amount Pension (If option is for lesser) commutation indicate the quantum No 10. Option of Return of Capital Yes (Please refer Serial Number 10 of INSTRUCTIONS) [Put a Tick ( )] If Yes, indicate your choice of alternative 11. Mention your Nominee for Return : of Capital Name : Relationship : Date of Birth : Address : 12. Particulars of Family : 1 2 3 SI. No. Name Date of Birth/Age Relationship with Member Indicate against Minor Guardian Relationship with Member (1) (2) (3) (4) (5) (6) Note : If any child is physically handicapped, please indicate "DISABLED" below the name. 13. Date of death of Member (if applicable) 14. Details of Saving Bank Account Opened (1) Name of the Bank (2) Name of the Branch (3) Full Post all Address PIN CODE SI.No Name of the Claimants(S) Saving Bank Accounts No. 14(A) If the claim is preferred by nominee, indicate his/her (1) Name : (2) Relationship : with the deceased Member 15. Details of Scheme Certificate Scheme Certificate received & enclosed Already in possession of the Not Received Member, if any Not Applicable If received, indicate: SI. Scheme Certificate Control No. Authority who issued the Scheme No certificate 16. If Pension is being drawn PPO No. Under E.P.S., 1995 issued by 17. Documents enclosed (Indicate as per the Instructions) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. RO SRO TO BE SUBMITTED IN DUPLICATE IN RESPECT OF EACH PERSON ELIGIBLE FOR PENSION Descriptive of Pensioner and his/her Specimen Signature/Thumb impression 1. Name of the Member : 2. E.P.F. Account Number : 3. Name of the Pensioner : 4. Father/Husband name : 5. Sex : 6. Nationality : 7. Religion : 8. Height : 9. Personal Marks of : 1.................. Identification 2.................. 10. Speciment signature of Pensioner : 1................. 2................. 3................. 10. (Only in the case of illiterate Claimant (Pensioner) Left Hand Finger Impression); THUMB INDEX MIDDLE RING SMALL Signature Name of attesting Authority Official Seal: Place : Date : Certified that: (i) I am not drawing Pension under Employees Pension Scheme, 1995: (ii) The particulars given in this application are true and correct. Signature of the applicant / Left hand Thumb Impression (TO BE FILLED IN BY THE EMPLOYER / AUTHORISED OFFICER OF THE ESTABLISHMENT) Certified that: (i) the particulars of the member are correct; (ii) the particulars of Wages and Pension Contribution for the period of 12 months preceeding the date of leaving service are as under :(In case, the wages is not earned for all 12 months, the block of 12 months will commence backwards from the last drawn) Year Month Wages Pension Details of period of noncontributory service. If there is no such period, indicate 'Nil' No of Days Amount Year No.of days for which no wages were earned (1) (2) (3) (4) (5) (6) (7) Encls: 1. Documents as given in the Instructions. 2. Form of descriptive roll and specimen signature. Signature of Employer/ Authorised Official of The Establishment with Seal & Date (FOR OFFICE USE ONLY) (PENSION SECTION / ACCOUNTS SECTION) Certified that the particulars in the application have been verified with the relevant concerned documents. The claimant is eligible for Pension. The Input Data Sheet is placed below for approval. Entered in Form 9/Form 3(PS), Master Ledger Card/Claim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant. CLERK S.S A.A.O A.P.F.C date date date date FOR USE IN PENSION PRE-AUDIT CELL The Input data sheet verified with reference to the application and the documents enclosed and found correct. P.P.O. may be generated through Computer. CLERK S.S A.A.O A.P.F.C(Pension) date date date date FOR USE IN PENSION DISBURSEMENT SECTION P.P.O. No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK S.S A.A.O A.P.F.C date date date date
