Forward Office Use Only
Inward No.
APPLICATION FOR MONTHLY PENSION
FORM 10-D(EPS)
EMPLOYEES PENSION SCHEME, 1995
(Read INSTRUCTIONS before filling in this Form)
1.
By whom the pension is Claimed ?
3.
(a) Member Name
(In Block Letters)
(b) Sex
(c) Marital Status
(d) Date of Birth/Age
(e) Parent/Spouse Name
:
:
:
:
E.P.F. Account Number
4.
2.
RO
Type of Pension Claimed.
SRO Establishment Code No.
Memberss Accounts No:
5.
6.
7.
8.
Name & Address of the establishment
:
in which the member was last employed
Date of Leaving Service
:
Reason for leaving Service
:
Address for communication
:
PIN: ______________________
9.
Option for commutation of 1/3 of Quantum:
Pension (If option is for lesser)
commutation indicate the quantum
Yes
No
Amount
10.
11.
12.
Option of Return of Capital
(Please refer Serial Number 10
of INSTRUCTIONS)
[Put a Tick ( )]
If Yes, indicate your choice
of alternative
Yes
Mention your Nominee for Return
of Capital
Name
Relationship
Date of Birth
Address
Particulars of Family
SI. No.
Name
No
Date of
Birth/Age
Relationship
with
Member
Indicate against Minor
Guardian
(1)
(2)
(3)
(4)
Note : If any child is physically handicapped, please indicate
DISABLED below the name.
13.
Date of death of Member
(if applicable)
14.
Details of Saving Bank
Account Opened
(1)
(2)
(3)
Name of the Bank
Name of the Branch
Full Post all Address
PIN CODE
(5)
Relationship
with Member
(6)
[Link]
Name of the Claimants(S)
Saving Bank Accounts No.
14(A) If the claim is preferred by nominee,
indicate his/her
(1) Name
:
(2) Relationship
:
with the deceased Member
15.
Details of Scheme Certificate
Scheme Certificate
received & enclosed
Already in possession of the
Not Received
Member, if any
Not Applicable
If received, indicate:
SI.
No
Scheme Certificate Control No.
Authority who issued the Scheme
certificate
16.
If Pension is being drawn
Under E.P.S., 1995
17.
Documents enclosed
(Indicate as per the Instructions)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
PPO No.
issued by
RO
SRO
TO BE SUBMITTED IN DUPLICATE IN RESPECT OF
EACH PERSON ELIGIBLE FOR PENSION
Descriptive of Pensioner and
his/her Specimen Signature/Thumb impression
1.
Name of the Member
:
2.
E.P.F. Account Number
3.
Name of the Pensioner
4.
Father/Husband name
5.
Sex
6.
Nationality
7.
Religion
8.
Height
9.
Personal Marks of
Identification
10.
1.
2.
Speciment signature of Pensioner
1
2
3
10.
(Only in the case of illiterate Claimant (Pensioner)
Left Hand Finger Impression);
THUMB
INDEX
MIDDLE
RING
SMALL
Signature
Name of attesting
Authority
Official Seal:
Place :
Date :
Certified that:
(i)
(ii)
I am not drawing Pension under Employees Pension Scheme, 1995:
The particulars given in this application are true and correct.
Signature of the applicant /
Left hand Thumb Impression
(TO BE FILLED IN BY THE EMPLOYER /
AUTHORISED OFFICER OF THE ESTABLISHMENT)
Certified that:
(i)
the particulars of the member are correct;
(ii)
the particulars of Wages and Pension Contribution for the period of 12 months
preceeding the date of leaving service are as under :(In case, the wages is not earned for all 12 months, the block of 12 months will
commence backwards from the last drawn)
Year
(1)
Encls:
Month
(2)
1.
2.
Wages
No of
Days
(3)
Pension
Amount
(4)
(5)
Details of period of noncontributory service. If there is
no such period, indicate Nil
Year
[Link] days for which no
wages were earned
(6)
(7)
Documents as given in the Instructions.
Form of descriptive roll and specimen signature.
Signature of Employer/
Authorised Official of
The Establishment with
Seal & Date
(FOR OFFICE USE ONLY)
(PENSION SECTION / ACCOUNTS SECTION)
Certified that the particulars in the application have been verified with the relevant
concerned documents. The claimant is eligible for Pension. The Input Data Sheet is placed
below for approval.
Entered in Form 9/Form 3(PS), Master Ledger Card/Claim Inward Register
Form 2(R) enclosed along with the documents furnished by the claimant.
CLERK
date
S.S
date
A.A.O
date
A.P.F.C
date
FOR USE IN PENSION PRE-AUDIT CELL
The Input data sheet verified with reference to the application and the documents enclosed
and found correct. P.P.O. may be generated through Computer.
CLERK
date
S.S
date
A.A.O
date
A.P.F.C(Pension)
date
FOR USE IN PENSION DISBURSEMENT SECTION
P.P.O. No
Date of issue to the Bank
Intimation sent to the Claimant
and also to Accounts Branch on
CLERK
date
S.S
date
A.A.O
date
A.P.F.C
date