PLEASE ATTACH TWO CANCELLED CHEQUE ALONGWITH THE FORM.

OTHERWISE
THE P.F. OFFICE DOES NOT ACCEPT THE FORM

Form 10 C
Guidelines to fill the Form 10C.

Very important message: This form has to be filled by all the members only if they wish to Withdraw
their Provident Fund Accumulation from HDFC Bank Ltd. Covered Employees PF Trust. If you wish to
Transfer the PF to your new organization then Form10C is not be submitted to us you have to fill in the
Form 13 in duplicate with your new organization.

1) Name : Your Full Name is Block Letter

B) Name of the Claimant : Your Full Name is Block Letter
2) Date Of Birth : Birth date is DD / MM / YYYY format
3) Father Name : Father Name
B) Husband’s Name : For Female Candidates if Joined the Organisation before
marriage then please attached the Marriage Certificate.
4) Name & Address of the Estb: Keep it blank will be updated by us
5) Code No & Account No : Keep it blank will be updated by us
6) Reason for Leaving Service : Resigned
B) Date of Leaving : Your Last working day in the organization
1. Your complete postal address Your complete postal address with mobile number

8 Are you willing to accept Scheme Certificate in

lieu of withdrawal benefit Yes / No
(Note if you wish to take the benefit of the Scheme after your retirement age then please opt for
option 1 ( Yes ) in that case RPFC will issue you a certificate which has to be surrendered to RPFC
on retirement.( Please enclose the birth certificate of your family member along with the form 10c if
your option is for scheme certificate & do not sign the Advance Stamp receipt on the last page. / But
if you wish to withdraw the money in full then you have to opt for second option.)
9 Particulars of Family ( Spouse , Children & Nominees : Please mention the details of your family
( Family means Wife & Children .
10 This column is applicable for The deceased members only
11) Mode of Remittance Your Bank Details Account Number with complete address
12) Are you availing pension under EPS –95 : Yes / No
( Please disclose if you are getting any pension from any of your Previous organization.)

After filling the above information please sign the declaration stating the above particulars are True
and to the best of my knowledge
13) Advance Stamp Receipt : If you wish to withdraw the accumulation please put a
Revenue stamp & your signature across it in the Advance Receipt this is compulsory.

(Please note Signatures are very important if your miss to sign then we will not be able to process the
form and sent to RPFC. This form is submitted to Regional PF office Bandra after remittance of the
last months contribution to RPFC and the settlement will be processed and credited to your bank a/c
by RPFC within a Time limit of 90 days.)
 FORM 10 C (EPS)

EMPLOYEES’ PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWL BENEFIT /SCHEME CERTIFICATE
(Read the instructions before filling up this form)

1) a) Name of the member :- (In Block Letters) :

________________________________________________________________

b) Name of the Claimant :

________________________________________________________________

2) Date of Birth : ________/___________/_______________

3) a) Father’s Name :
________________________________________________________________

b) Husband’s Name (if applicable) :

________________________________________________________________

4) Name & Address of the Establishment HDFC BANK LTD.,

PAD - FINANCE,
LODHA - I THINK TECHNO CAMPUS
BUILDING - ALPHA, 8TH FLOOR,
NEXT TO KANJUR MARG RAILWAY STATION (EAST),
KANJUR MARG (E), MUMBAI 400042

In which, the member was last employed. :

5) Code No. & Account No. : MH / 46135 /

6) Reason for leaving service : RESIGNED

& Date of leaving : _____/_________/___________

7) Address : _______________________________________________________________

________________________________________________________________

Tel : Number ___________________________ Moblie No. __________________________

E-Mail ID __________________________________
8) Are You willing to accept Scheme
Certificate in lieu of withdrawal benefit : Yes No
9) Particular of Family (Spouse, Children & Nominees)

Family Member Name Date of Birth Relationship With Member Name of the guardian of minor
10) Incase of death of member after :
attaining the age of 58yrs without
filling the claims
(a) Date of death of member :
________________________________________________________________

(b) Name of the Claiment(s) and

Relationship with the member : ______________________________________________________________

11) MODE OF REMITTANCE (PUT A RICJ IN THE BOX AGAINST THE ONE OPTED)
A) By postal money order at my cost to the address given against item no 7.
B) By account payee Cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation to me.

S.B. Account No. : ______________________________

Name of the Bank (In Block letter : _________________________________________________________________

Branch Name (in Block Letter) : _________________________________________________________________

Full Addresses of the Branch : _________________________________________________________________

(In Block Letters)
_________________________________________________________________
12) Are your availing pension under EPS-95

If so, indicate ` : _________________________________________________________________

_________________________________________________________________________________________________________________

CERTIFIED THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date ___/_____/_______ Signature or left Hand Thumb Impression of the Member / Claiment
__________________________________________________________________________________________________________________

13) ADVANCE STAMP RECEIPT

( TO BE FURNISHED ONLY IN CSE OF (B ) ABOVE )

RECEIVES A SUM OF Rs. _________________ (Rupees _______________________________________________________only) from

Regional Provident Fund Commissioner / Officer In Charge of Sub – Regional Office____________________ by deposit in my saving

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 / Office-in-Charge)

Afix
Rupee 01
Revenue
Stamp
Signature or left Hand Thumb Impression of the Member / Claimant
 (FOR THE USE OF COMMISSIONER’S OFFICE)

(Under Rs. _______________________ P.I ____________________M. O/ Cheque passed payment for Rs. ________________________

(in words _________________________________________________________________ M. O ( if any)_______________________________

Net amount to be paid by M.O ______________________ towards withdrawal benefit

C.C S.S A.A.O

(FOR USE IN CASH 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 scheme Certificate, Input Data Sheet is enclosed

C.C S.S A.A.O APFC (A/cs)

(FOR USE IN PENSION SECTION)

Scheme Certificate bearing the control No. __________ issued on _____________and entered in the scheme Certificate Control Register.

C.C S.S A.A.O APFC (Pension)