EMPLOYEES’ PENSION SCHEME, 1995
Form 10-C (EPS)
Form for claiming withdrawal benefit / Scheme Certificate
INSTRUCTIONS:
Form No. 10-C is to be filled for up withdrawal benefit if service is 6 months or more.
Who can apply ?
1. A member of the Employees’ Family Pension Scheme, 1971 / Employees’ Pension Scheme, 1995.
(a). Who has left the employment before completion of 10 years service.
(b). Who has attained the age of 58 years before completion of 10 years service – whether in service / left the service.
(c). Family / legal heir can prefer the withdrawal benefit claim in the case of a member, who attained the age of 58 years before completion of 10 years of eligible service and died thereafter without claiming the said benefits.
2. A member, who has completed 10 years service on the date of his leaving the service and has not attained the age3 of 50 years on the date of a filing this application or has attained the age of 50 years on the date of filing this application or has attained the age of 50 years or more but less than 58 years and not willing for reduced pension.
Note : 1. To determine the period of 10 years service rendered from 1-3-1971 to 15-11-1995 (if any) shall also be taken.
2. (i). A member, who has completed 10 years service and attained the age of 58 years, whether in service or not, is eligible for Monthly Member Pension.
(ii). A member, who has completed 10 years service and also attained the age of 50 years is eligible to draw pension at reduced rate, after leaving the employment.
(iii). A member, who has left the service on account of total and permanent disablement, irrespective of his and period of service, is eligible for monthly disablement pension.
(iv). To claim the Monthly pension, application in Form 10-D should be submitted.
3. Type of benefit eligible
A member falling under item I above is eligible to get the amount towards withdrawal benefit.
However, a member failing under item 1(a) above is advised to opt for the Scheme Certificate on account of following advantages:
(i). On taking up employment in another establishment, his earlier service period will be carried forward and clubbing both the spells together pension entitlement shall be regulated.
(ii). If the member does not take up employment and dies before attaing the age of 58 years. His family will get family pension. On his survival, he will get withdrawal benefit with weightage as may be prescribed.
(iii). While availing a Scheme Certificate, there is no bar to withdraw the P.F. accumulation by the member.
(iv). From No. 10-C is to be filled up for withdrawal benefit if service is 6 months or more.
4. Guidance for filling the application :
(Sr. No. given below refers to the one given in the application.)
Sr. No. 1(a) : Write your name in CAPITAL letters as given in the service record of your establishment.
1(b) : To be furnished only when the application preferred by a person other than the member himself (i.e. Nominee/family member)
2 : The exact date of birth of the member should be given.
3 to 7 : Particulars should be written clearly without any overwriting of cutting, Correction if any, be attested.
8 : The option is to be given by the member only if he not rendered 10 years service and eligible for withdrawal benefit.
9 : Complete particulars if nominee and family (spouse and all children) should be given without fall.
10 : To be furnished when the claim is preferred by nominee of the family member(s).
11 : To be completed only when a member is eligible for withdrawal benefit and opted for it in lieu of Scheme Certificate (not applicable to those who are entitled for Scheme Certificate or opted for Scheme Certificate in lieu of withdrawal benefit.)
12 : In case, the member is drawing Family Pension / Pension under the Employees’ Pension Scheme 1995, the details should be furnished.
Advance Report :
To be given where the withdrawal benefit is admissible and opted for payment by cheque.(The Advance Receipt need not be signed by member, if the payment is opted through Money order).
Attestation of claim form :
The claim should preferable be attested by the employer under whom the member was last employed. If for any reason, the claimant is unable to get the application attested by his exemployer, he may forward the claim to the Provident Fund Office duly clarifying the position, after getting it attested by any one of the following authorized officials :
(i). Manager of the Bank where the member is holding an account.
(ii). Head of Education Institution
(iii). A Gazetted Officer
(iv). Sub-Post Master
(v). The Magistrate
(vi). Member of Central Board of Trustees, Employees’ Provident Fund or Regional Committee.
(vii). Chairman / Secretary / Panchayat / Member of the Muncipal / District / Local Board.
(viii). President of the village Union / Panchayat / Member of parliament / Member of Legislative Assembly.
(ix). Any other officer approved by the Regional P. F. Commissioner.
5. Four further guidance / clarification required, if any, the Public Relation Officer in the nearest Provident Fund Office (including Provident Fund Inspectorates) may be contacted.
6. The status of the claim can be verified from the website www.epfindia.com
Form available fee of cost.
A. C. Gr. No. ___________
Serial No. _____________
Employer’s Tel. No. : ______________
Member’s or Contect Tel. No : _______
Inquiry Tel. No. : 27542251
Website : www.epfindia.com
For Office use only
Inward No.
Form No. 10-C (E.P.S.)
EMPLOYEES’ PENSION SCHEME, 1995
Form to be used by a member of the Employees’ Pension Scheme, 1995 for Claming Withdrawal benefit / Scheme Certificate
(Read INSTRUCTIONS before filling in this form)
Form No. 10-C is to be filled for up withdrawal benefit if service is 6 months or more.
1. Name of the Member :
(In Block Letter)
Name of the claimant(s) :
2. Date of Birth :
3. Marital Status :
4. Father’s Name :
Husband’s Name :
(if applicable) :
5. Name & address of the Establishment in which, the member was last employed :
Region/SRO Code
Esstt. Code No.
A/c. No.
6. Code No. & Account No.
7. Reason for leaving service & Date of leaving :
8. Full Postal Address
(In Block Letters)
Shri/Smt./Kum./S/o / W/o / D/o
:
PIN
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
(A) Family Member
(B) Nominee
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) By postal 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. :
Name of the Bank :
(In Block Letters)
Branch :
(In Block Letters)
Full Address of the Branch :
(In Block Letters)
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:
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 / Officer- in Charge)
Signature & left hand thumb impression of the member on the stamp
Affix Rs. 1/- Revenue 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 Employee’s Provident Fund Office.)
Wages (Basic + D.A.) as 15-11-95(if applicable)
:
Wages as on the date of exit
:
Period of non contributory Service
:
Year/Month/No. of Days
:
Date:
Signature of Employer / Authorised Offical
(FOR THE USE OF COMMISSIONER’S 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.
A.A.O.
(FOR USE IN CASE 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 S.S.I.D.S. is enclosed.
D.H.
S.S
A.A.O.
APFC(A/cs)
(FOR USE IN PENSION SECTION)
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(A/cs)