FORM No.5(P.S.) FORM No.5(P.S.) (For Exempted Establishments Only) THE EMPLOYEES' PENSION SCHEME-1995[Paragraph 20(2)] Return of Members Leaving Service During The Month of .......20 Name & Address of Establishment .......................... Code No. o f the Establishment ........... Sl. No. Account No. Name of the Member (in block letters) Father's Name or Husband's Name (incase of married women) Date of leaving Service *Reasons for leaving service (See note given bellow) Remarks (1) (2) (3) (4) (5) (6) (7) NOTE: Please state the member is (a) retiring (b) leaving India for permanent settlement aboard, (c)retrenchment, (d)Permanent & total disablement due to employment injury, (e) discharged, (f) resigning from or leaving service. (g) taking up employme t elsewhere, (The name and address of the employer should be stated), (h) dead &(i)attained age of 58 years. Signature of the Employer and Stamp of the Establishment.
