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. of 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 employment 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.