'

/l$ xoe:.
;ci6 "
Seial

.rd .

r6-ditrl\

twffil

No.

For ofiice lse only/ lnwad

dEDrdd fJodrd oSroe6d

o.dqti ftrq frqa1

Of,gA3

19e5
EMPLOYEES' PENSION SCHEME, 1995
ddJod r0 a (Ei.&.o!og c[d 10 ff (atid)F;rm io c (EF$
odrotD Eoao.d aorj.d olirEi, rr95d ldritrod d.o aoaoilg/olacEE! $ds6 dg *dotjo:/t^)doJ,a![ier
.i+?rrt +rra ir'r{r .Egs i tn'q ;r,i !-lq?ir qia.,r ; drf,fl eq; .r s zlq.r dri + iqq
Form to be used by a member of lhe Employee s Pension Scheme, 1995 for ctaiming

(sdFoidl
(J)

qigF

Wihdlawa Benefvscheme Cerffi..arj

nrn?-jdc$.b{ d,o@) i {er+{q ,l{*

Red the lnstruction caretuly beforc lilling up ihis io

;S.drd d,ado

+ rr{A qTq- +,+)

idird dnd (aa eddnc-g)

F{q Fr irq (Fq o{ct-{t q)
Name of the lvember(in Btock Leiiets)

rJ) edF6idd dnu)

sr+qR / qr+{6 (+)

fi

nrq

Name of the ctaimant (s)

2.

sdai 6daod /q;q fdfq

L__r

Date oi Bldh

3. s)

dodon

di6

/RdriTrrFr

' L=]: -T-:t_:.t

Fathe/s Name

s)

dodd dicb / qh 6r Taq

Husband's/Spouse s Name

((9*:$6Drbd@Cd

irXtd

idlb$ don drD6d iodo$ dndl

F{q Fir Frq Isqf ?It fiF{I fi nrq

4.

Name of the esiEblishmenl in which

ifi l4ember was tast emptoyed

*,ne6. !oaj,

5.

d6

aDS

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Jog

Code No. andAccouni No

tst ddc) rodra dr6 E:r,r AB 6 Doi

+tq de+ + frq 61ttr { 6q # qr ;ro

ela

v.+. Fr.

Rogion

SRO Code

f4Nl

e{s{t Fts *qr {qr

Estt Co{io A./c. No.

r--_lt.____--.i

Reason ior leavtng servic e,ld Date of Leaving

1.

atoDa a9-rj

/ T{

gr/q,e$J/6drDb/4/
shn/Smt./Kuman

rrdr

ffir / Flt

edd 6d/ dg,/ ;$,1it + Tr /rcff

S/o.

ll//o.

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/{*

d|o Fo*i3dL rjdej o3r.r:51 65n.

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d,io5 r.ro$$o6n r
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q-fq
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+ fr.rlr{ mr,rl ]fq:5r'
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iPlea* tc{ apllpiate c.rmn)
Ri ----]
i(ere. ,lsrrJclon shee!)
ye. l____l

vou wi Lns ro ?ccepr

scnem!
orwth.trrxa, oer..irs

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9.

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qrs6 Fr ;tr'r
dnd)
&iid oJoos Fqq q trqq
qs
Name ofthe
frfq
Rebtionship wth
aFI
guadian
Date ol Blith rnember
Name

Padicularc of Fami! (Spo!se, Children &

.ir i)t5oud

s)
t0.

ndi.o)

Fiq:o;J/qdi+d / Nominee

:can: (L ):r iorl{ni.ri e:ii igiCf Ddf: d''b60

h
H * i.qir "+ ** + 'r "*.i eq F+r Tt Ear withoul
liing the
lhe ageot
ofdeath ot memblr afier
veals
h
ei

a)

Jdn6n

$dr! 6-non

/({{r {n Tq
fi.'nber

al,le of death of the

e{i6

claior

J,oir: , "cr-oo
'' inFbr Riltr
Name of the Claimant{s) aild relatonship with the member

(,?tr-rron dro, at
qr+e- i6r a]lr a fr

,,
t1.

58

atlain ng

case

dm ,o6rctl)js3cn)d

oe,g

{r r{R ({cFd

(abod

+.tl I /

n"a?,3t

d 6:ooiiq V

?DoJsa)

a.Ilq)

V ln ihe box against lhe one opled)

ioi3 Tdo l,,a?!rd thit.ld.d o.3iijo 1i,o:'r:Ers' iYni (*e2000/-ddii -.*onc?i dLg) -l
q* ' + z"rt gq rt # lar bt d A ernrdlr 6r ,+ar t2000' -o:lz)
L

Mode of remitlance (put

a)

tick

ey F,oslar money order at my cost oi the address glven againsl ltem No 7 Payble uplo Rs. 2,0001 onlv)

..: r.s3io! J33(ear,(J :ri.)./ i (,.-)o'r ird. z3n.r !!J::)so.Jrid 99ra9d ridlJoor
,+ qcn e6J i'u- ]lcj iEn"+6 r'T rryfl A",ii ''+rre :ir,.ra eF- rs, 6,i * ftq
fl
Ac.oulr tayee cheoue se.l d ecl to' crcoil Io r/ S B A'cl'sc'reoJleo Bar \r
e1q.' , .,'r:1 {oe.3. a i. a
S.B.

A,r

No.

r"dosn

i$cb Fl6 sr qrq

lId:Jo]J

dn$ /snq fi Tl

qdl

FuliAddress of the Eranch

c) Sr aairi"or*ffittq.i oFr+r:di?rrlnF.i+ii'{ By NEFT pnymonr ro my sB A/c. rhoush co6 Bankrns sysrsD

d) Ivlandatory : Please enclose aitested copy offtsl page of pass Book / Cancelled IIICR cheque leaf
y.,6ui : c;c.'r): LaoF
=d !166 r:13= !at:d {,Jo1'S u\drja-3J llaoi^oan do::lL]i o.llns."6d
qs r e{il *6 + qr{ gqr * qf* y!6 + Frfia{I vfi ii trlr6 qRr flF{rFrd 6{ + ?F{r +fi st
I

Nole:Pleaseenclosexeroxcopyoftirctp3geofS.E.A/c.PassAookdulyattestodbyemployerfor

the

co ect pady.
12. :.rij nd4d ac,.!!i d,o.N.J l995d ali?d d,o?:d ndc!l),g$ic!? 6ntrd:9 eea a.dJ.l" dc9.)crr............_............
!doq(o,? 6.nqo gdrili
" " .. .. .. .. ..... .. .... erFar rrd caa.r.n rni6
onsurlng that

cheque reachG tothe

"-jg
3.j"9. :lt:1ud
.s ,{r" 6F{d- ilF ,+rFr t99s + , rIFts +e-i rq f, {; ir llqr t rr ff ff.Tr {Gn {Fi.n si
';q; J-irqr-dlnt........... .............. . zn c-Fr rrlq qr 6r aifl...... .... .'.. . ..........

Ale you ava ing ionsion under EPS 1 995, li so, Indicale PPo. No. ............_... _ --. -,-_''.'..........and by whan lso,eC
. ....................or hav y.iu availed Sche:i. Ced lical! ead er, I sr. i dicrre Scheme Certit cate No.._........... . .................

!.d

i3.

Ti

by

s(,n

+dT3n

ssuFd.........

,5 .+{r .e.R

Dlails oj larlierservices

ii

nde6 (ifany)l

3-

;t-!nd 'od) {-aFDcdoir4ed

a;if+'}
n'n6i- 6 TaI.i6 FE f
tEd
ft
b

g1 d)eod odd,'ld)

q{Fr{

Gqr

fldr

nnd 396 d){d

knowledge
Cdified lhai ihe paidculaE arc true io ihe best of mv
instructions
and I have gone through the above parloularc &

rrc' .E{ d{g tosll

n6!,. / @srclod 16

({q

/Er+{R

* EKI{{ / slii qfq T[o- *

lMPREssloN

slGNAtuRE / LEFT / RI.HT HAND THUMB

OF THE MEMBER / CLAIII/IANT (S}

il;",.:--.........................

;ItIi

NAME :

{-qt PF A/c. No/ KN/

or:e .j.ra / qEq c rfi-(
sT.f{.+qr

,iGo,r*

/dreod

ADVANCE STAMPED RECEIPT

a'o5;n- r.,nzlidq Ln'tr Mad6!r*, (s(.n-,s dq"i +
{To befurnished onlv in case ot b abovo)

;oaritde

n6 sor.!q6,6oc'.FDo
g-Y 3:c
?d0o6 d,o. .........-..-

fri*o-io. io*a
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+ }.qd Fi)

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ol
. . . . . . . . On]v) lrom Reqlonal Providenl Eund Commisslonermv/ OfllceFin-chaQe
a"ni
rnt
Fund
Pnsion
ol
ihe
senrement
iiji-ii"s;"filt1";... .. . . b/ dePosli rn ;v savinss Bank A'lc rowards
acr{4)
'{!Dd ;"ars zjla. 10 6debor)q Doa;e) l]!O
.r*s n. * iecq ftfu 6tot{a n lFA * i\ qrtl 6ir ''rr ')
.-.-.'...--:.'-.'.......-........- .

o","toua {|'ca

',t,-,",0.*

<l-al oe Fled bv Regiotal P ovdenl

fuld

"no",oicerin-chaEe)
conmissioner/off

d{tld ?!d4)
dii.n, x.po $eej rdqD 6d ^drl / Dori,rqF
qq{a'ft+a qr {aq sr i<reF iElii i iai?i rr:;r
/

Leli / Right hand thumb impression ot

$e member on

th9 stamp

rs mq-6 sr qEFTITIFT ATTESTATIoN oF EMPLoYER

$.d dr?6 ior."! aior$ rr.oinn i1-o^l :Ja^ ii.tF l6qE od inl <lJdroq or/6*iF ru6$ 6a!6Bd
q
!q+6 qrz #qh a)n#r+g ?a eq lI n"a{.q,El+arr t} 'fr4i Eq"r' AqTdl slc;FrFlr I
Certfied Ui lhe above Parliculars of

r6ra)

;;

the;ember

glven

a coned

and the membet has signed/

.! o i$ 610 d!5oo$d6 iedoo a on$ 6{ itRnoJd

* ;.ft di. ; -dr ;rd{ +qr "rdfq F F{r ir<c? i

Thlmb implession beir me

IouJed

The delails oi wages and period of non coniribulory service of the member arc as under

rsnd(gn i!&rr

i6

elQo$ na),o"3 .r-4 93o$q odltetDnd)

q*r wq e{ ar ru/7 *ss q'"Fftirt r)

toofrFe)o$d, 6qrr&i6

hFi *rqtaq

id+- "rft31," (EPS) enclosed

iFom

+1

,lir

for ihe Pedod for which it was not sent to Employees' Provident Fund Ofiice)

d:gir (a)jae Jesn+$$Pir) ls-ll-lansdgqod roqcioEr-'P)6ndd r5tr3.

Fi. I ts-tt-tgss aq (qtq =r: fi {r )
+{n (Ta +d{ ,d

l:

Wages (Basic+DA) as on 15-11 1995 (ifapplicable):

ieiJobod ?:6 6.tdoddod! dEjedd

frer

# * F<ic or *ac

Wages a6 on the daie of exit

*Ddeceodd

R-{r sisr4F

iedo$

(JdQ

+qr erqft

q{

iqe

6d?id)

ff{

Period oi non coniribuicry service

irom 1-3-71 io date bf leaving service

{s{E{{rdr

+l

q{

$m

ii_. nFiq)

(Please atach sepamte sheet ii necessary)

d&Odd / oAiS cQiloo$ 6co. dJi6(t

Fqr-{6 , sriD-f( *f*6rft + qKRlt t'r qFd
SIGNAIURE OF EMPLOYER / AUTHORISED OFFICIAL
wlTH SEAL

(so${d tdc6cd

{.DdoLacn{

ssg ({r{!lr *

{r<itffi

{FOR USE OF COMMISSTONER'S OFFICE)

dn./

e(rrir

* frc/

'

,-Cdei a$. nodd

6.

Pl No ..................,,,..,,..,....-..-.
..$aoJrndFd/dd/ uarin I tr,tol
/ 5./

dJ'a5ro$

I . .. .....

.... (sgd?icg) ({rdr

+)(lnwords)

trndg?ite4d sdconejnnd

... ..only)

Ctreque

/ * t{FrE + 1iq qr-Fd /Passed

lor pavmenl

oo& .bssletJ de edCo! n{C ed.s

tladsrErtriq qs{i{6q.
r<r.','rregr (a-..-<5ot*)..
. .... nel amount lo be paid by M O lowards wilhdrawal benelil
M.O. Commission {il a y) .. ...

oijf.6.

dor-iJ6.............................

d)).

lbdtbi

$*oi

dEb

6roo

e.+i6Yti

A.O.
s.s.
(dn& aaorldg .odoi."cri:J / (n6s 4{qFr + sq"dq + ftC)

D.A.

(FOR USE lN CASH SEGTION)

dddr do4i (r:ooot)

$.3 io4 l0{ r.5F ,oej5 ....-.-. .

....ob ed.lo$${ i(oictdnd.

idTZ{ (+d)eqr{iqr

10+nrl{{

yrdrd + ftq crFrT

N.

iqr.............-................. ..G-{i6

...

....

--

"

d dd} nodr

.. ... . ++dd@r'

..

..

ERr

Paid by inclusive in Cheque

a..ornr

..... ... -.-. - 6.ttod

Debil

e;

.di.

-..

..... . .

.. ...

vide Cash Book (Bank)

No.........

i. 'io$)q (d?i$)
irrgtr
FEIT{
S,S
{*rd)/A.C. (Cash}
oSrrIJro qlahDro ag ?3nbdo?nen e.r"rC,ut 6.aD oet"i lrnqicxnd.
qtq<r cqlll {5 qrft 6{t tg {{ga cadl '.fts a.rErcr t I
dD.

?il

{IlrFl tr4iFr /

For issue ol scheme cerlificate lDs is enclosed

doonDo
4.q.

fa&-6

i. sollidr aeld r
q.t.li.!il (.Er)

AO.

(arodrd aqrn dO sldo3icrieJ

drl{ {{iTFI

qt[q]n

+ ftq)

1FOR USE tN PENSTON SECTION)

n.\no!iA. !or1 .-.....-..............................._d,6oo&d olreIJdD gtrcla dlddd od!oi........._.........dod lsnod.oe:jeDnd

drd) ol,"e?3F! drlo dgi OonolF dntdg ,rdo$o.Rd.
rr"rc rirrqr 9;rrr qa 6T Q-riq . .....................Fr:rrni+-arqqrt nq zFanr
furq

iEqr

rcrvl qe

ff.i""r 1Bs{ + ftqFr{r

Schome Cerlllicaie bearing lhe Controt No...................._...................tssred on.............................and nle16.l in

Scler.e Cerl/ cale Conrro. Fegisrer

.b*:

ftR-i/D-.A.

d):. rb
dEb.eEoo
q.c./s.s.
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ile

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