EMPLOYEE rrp: E- MAL ZD:- stags #./ Mobile Number 9000 xxx} es thea owen For Office Use Only re #/Ciaim LO rer dy faa) Form No 10-C(E.S,) srerh e ara,o85 EMPLOYEES’ PENSION SCHEME, 1995 fut to deste & era gm a Rt sfters (a paea fy wn Foe a ue FORMATO BE USED BY A MEMBER OF THE EWPLOYEES’ PENSION SCHEME #95 FOR CLAIMING WITHDRAWAL BENEFIT/SCHME CERTIFICATE rot ooh et Po 2 {Read the instructions before fling up this form) {2}, SER Em Ge we #7 Name ofthe Member (in Block eters: DEEPAK SwAM! = [Name of the claimant (3: DEEPAK SWAMI 2. sRR/ Date of Birth. (ddlmmiyveNT Gc oe fem a am fathers Nome__ SH. BL. Swam 2&1 am Husband's Name it applicable) sh Busi 88 Servi . Led. 4. xaen sam a Brel ees dr Pri a} _TBM Daksh Business Process Services Prt. Name & Aderess ofthe tio Establishment in which, Se the member was ait emplaved 5. mam men am By 7 Tt ector-25A, Gurfaon-122002, Haryana fon me Code He. Account No Retin/SRO Code GIN ala ‘ora a 1 {st Code No, New 1ob4o. |] [eexx 5A) wrtts Af/Onteofoningthe et, 13 — Tan’ = 2004 : : de tea wero frost a aR __ RESIGWATION. Ai = TuLy - 20)3_ ee Reason for leaving service & Date of Leaving 2 sum (roe et Full Adress Block letters) arg /5h. smtp. DEEPAR SiJAM wrt s8/5/6, wle,ofo,_ SH B.L- SWAM) —exyadms HOUSE No. - Jol SecreR- 1S, jon’ (HARYANA, __ syn _ 1220 Beer & eee AR oe to wer fran & cent Employer's Signature Slaraure or et / Right and thumb imresion of theruember " a8 /P.T0 wvn.ptnin ginBaeza Petre en eT {es eae aA Pe fa Bs « @ ‘ce you wiling to accept Scheme Cerifcate @ ww) ‘alow of withdrawal benefis * * ~ Cow 8. fae oe (8/0 ae eh nen Particulars of ari Spouse & Cilren & Nominee) : (Fe arse sor wa 3 Flea & Fe /apwicabe ony for Scheme Cette option) a aa ee wre a a aa sat afore a a . Name __pateof sith __Relaionship with Member__ are of the guardian of minor tae (2) Famiy members —— SaUtE f=) 3am ~~ ae {8)__Nomine 1 Rrawita a auger sd dae eR Incase of death of members after atisiing the age af 58 years without filing the claim (2) Trea Bey oh ARL/Dae of death ofthe member (8) sherds /en wera # ER HE /Name ofthe Claminantsand relationship wth the member 211, seer am me Ren AD ae ia ae Hr) ‘Mode of remittance (puts tckin the box against the one opted fee T Aye AR a me aE x {ay postat money order at my cost tothe addres given agains item No.7 FR as et gy A ay eT MOTTGfAN fe /arom) § Rn / ERUETR em A amen era AY Aen SI (A) By account ayes cheque/ electronic made sent Directly for eect to my S 8, A/C {Scheduled Bank P.O) under intation to me = ‘say Ba 4/58, Account No, 151023405130 ‘Ys a Pr (Te oUt A/Name of the Bank (In Block Letters) HFC BANK. ‘we (re Set 8] Branch in Block Letters) —GurGhor (yaryana) saben. 318/ 1FS Code —HIeL conouy sor 5 (ea H/F adres of he Branch in lockLewers) o= : y ~ 26, Haryana) 12, eam 68 th 953 em Be Bra we eB? ‘re vou avaling pension under EPS-95 7 ne 8/40 Ra dha wt tt fect ar a "ye, neeate PPONo... ay whom issue. 7 Seat rar or & Fr Fae AR Rr SI SEE aN 2 / eve that the parties ave ue othe best ot my nowledge ee Pe Signature or let Wand Thumb impression ofthe Member/Climant ate Protea eens /employers Signature ‘wat epfinda goin— msieatsy er a sr ren etc 6 gent et fc ences ee Natalee at ger * aon Ago Pa Yd Canarias Sse nia" ahh sen den ttencinettneren orate Facies ne erneoiremeren seyret tre te il be TN eye Provident Fund CommissionecOficer in-charge) fea we ween & eee RE Be aT oF Aer ‘Sigtiature & left hand thumb impression ofthe member on tne stamp ‘roi fat oer Feces er fey rem ah # abe were AA eet ee Py ats Pret cod) Certified that the particulars of the member given are correct and the member has signedithumb impressed before me. ee A IRAE AT seeeh rae fe Pep = ‘The details of wages and period of non-contributory service of the member are as under: trera—ag 7) Reh) er er 8 Fret oR gM amb aN HRY wh SH aA oe (Form 34/7 (EPS) enclosed for the period for which it was not sent to Employees’ Provident Fund Office) fe noes wt gh Be ne xa Ea x Wages (Basic +0.A) as on 15.11.95 ( applicable) x re wt | Wages as onthe dato of exit x ‘he scene a Period of non contributory Service: tyme a Year/Menth No. ef days ; eae ea arts sat & era Date Signature of Employer/Authorsed Official angen ree hed (For the use of commissioner's office) x Bat /seref ae, tale Under & P.LNo. M.O.Cheque x wee - ‘wero by wg Pm), Passed foc payment for & (Gn words) : arse te GE mi 8 - Fra far Ba 4 M.0.Commission (ary) het amount tobe pal by MO. towards withdrawal benef. am Sd wast De, SS. AAO. ‘wwwepfindla. gov in(rep ctrl (For use in Cash Section} aan eeme rn 72 Ft ese fy nto tte we Roimtat aid by inclusion n cheque No, ot side Cash Book (Bank) Account No. 10 Debt | item No. : sant no oe ss ‘AC (Cash) em af a & Ry aed TB For issue of S.C., 10S is enclosed aR setae samon (a OM SS KAO. APEC (Accs. pe & mies) (For use in Persion Section) PE EB PRE Hf faa, 8 fovin 2) nf rm te ge fe opm sooner Pras A 8H Scheme Cettitate bearing the control No issued on ane, entered in the Scheme Cerificate Control Register | aR qu aa aman (an) Oe. Ss. ARO. APEC (Ales) wun epindla.govin