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/Smt. /Km. CH SIMHACHALAM iq iRuh iq h S/o W/o D/o. irk Adress D NO 15-2-24 MADHURA NAGAR HYD 512345 EMPLOYEE SIGNATURE lnL ds gLrk kj vFkok ck a nk a gkFk ds vaxwBs dk fu kku Signature or Left / Right hand thumb impression of the member Form 10C www. D. fudklh ifjYkkHk kstuk izek. ki ds nkos gsrq iz ksx fd k tkus okyk izi 10 lh FORM 10C FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE deZpkjh is a ku kstuk 1995 EMPLOYEES PENSION SCHEME 1995 izi Hkjus ls igys funsZ kksa dks i s a Read the...instructions before filing up this form fn lnL rk 180 fnu xSj va knk h lsok dks NksM dj ls de dh gS rks izR kgj. eksckby la- Mobile Number Mobile Number dsoy dk kZYk ds iz ksxkFkZ For Office Use Only nkok la k Clam I. k ykHk ns ugh gSaA WITHDRAWAL BENEFIT IS NOT ADMISSIBLE IF MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRIBUTING PERIOD CHAPPA HAREESH d lnL dk uke Li V v kjksa es a Name of the Member In Block Letters k nkosnkj dk uke Name of the claimant s tUefrfFk Date of Birth dd/mm/yyyy...firk dk uke /Father s Name CHAPPA SIMHACHALAM ifr dk uke Husband s Name If applicable ADDRESS STAMP OF THE COMPANY LFkkiuk dk uke o irk ftlesa lnL var esa fu ksftr FkkA Name Address of the Establishment in which the member was last employed dksM la- rFkk kkrk la ks dk dksM LFkkiuk dh dksM la kkrk laCode No* Account No* Region/Off Code Estt. Code No* A/c No* G R 5A V S P 0036833000 0000123 01-01-2017 dk kZjaHk frfFk Date of Joining the Estt. lsok NksM us dk dkj. k rFkk lsok NksM us dh frfFk...Reason for leaving service RESIGNED ALWAY BETTER TO WRITE RESIGNED Date of Leaving iwjk irk Li V v kjksa es a Full Address In Block Letters Jh Jherh dqekjh Sh. epfindia*gov*in EMPLOYER SIGN WITH AUTHORIZED STAMP fu ksDrk ds gLrk kj /Employer s Signature Page 1 of 4 D k vki fudklh ifjYkkHk ds LFkku ij kstuk gkWa Yes ugha No izek. ki Lohdkj djus ds fy rS kj gSaA Are you willing to accept Scheme Certificate in lieu of withdrawal benefits Withdrawal benefit is not admissible if the membership is...less than 180 days excluding non contributory period of service. ifjokj dk fooj. k ifr iRuh rFkk cPps rFkk ukfefr Particulars of Family Spouse Children Nominee flQZ kstuk izek. k i ds fodYi ds fy applicable only for Scheme Certificate option uke tUe frfFk lnL ds lkFk laca/k ukckfyd ds vfoHkkod dk uke Name Date of Birth Relationship with Member Name of the guardian of minor ifjokj ds lnL Family members d a k b ukfefr Nomine fcuk nkok fn 58 o kZ dh vk q izkIr djus ds ckn lnL dh e R q gksus ij In...case of death of members after attaining the age of 58 years without filling the claim lnL dh e R q dh frfFk Date of death of the member nkosnkjks ds uke rFkk lnL ls mldk laca/k Name of the Claminant s /and relationship with the member /kuizs k. k dk ek/ e fodfYir fof/k ds vuqlkj lacaf/kr dks Vd esa fVd djsa Mode of remittance put a tick in the box against the one opted en la- 7 esa fn irs ij esjh ykxr ij Mkd euhvkMZj kjk By postal money order at my cost to the address given against item No*7 eq...s lwfpr djrs gq esjs cpr kkrk la- vuqlfw pr cSad Mkd kj esa js kfdar psd bysDV kWfud ek/ e ls vknkrk kkrk lh/ks Hkstk tk b By account payees cheque/ electronic mode sent Directly for credit to my S*B.