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No: CPF-V/32 (33)/95-Pension/07-08 Dated: 29.01.2008 To All Executive Director (Zones), All General Manager (Regions), All Area Managers, Food Corporation of India, _________________________

Subject: EPS 1995 Check list for forwarding the pension cases.

Sir,

As you are aware, Employees Pension Scheme (EPS 1995) has been launched w.e.f. 16.11.1995, which is applicable to all the

employees, who have joined on or after 16.11.1995. Besides, in

view of the Supreme Court judgement dated 11.11.2003, all the members of FPS 1971 have been automatically covered under this

Scheme. Even this Scheme covers those employees who were not members of FPS 1971 but have exercised the option before attaining the age of 58 years and submitted the full contribution w.e.f. 01.03.1971 along with applicable interest.

A member/beneficiary of EPS 1995, who is entitled to draw

pension, must apply in Form 10 D, duly filled in, to the RPFC, having jurisdiction, where his/her contribution has been remitted

by the employer along with other requisite documents which would be forwarded by the FCI. As per clause 17-A of EPS 1995, the

claims, complete in all respects submitted along with the requisite documents shall be settled and benefit amount paid to the

beneficiaries within 30 days from the date of receipt by the Commissioner. If there is any deficiency in the claim, the same shall be recorded in writing and communicated to the applicant [and

not to FCI] within 30 days from the date of receipt of such application. Every member has also to fill the Form duly forwarded

by their respective office for allotment of Social Security Number (SSN) (copy enclosed) for forwarding the same to the concerned

RPFC.

A member can choose Any Date from the date of exit from ‘service’ or attainment of 50 years, whichever is later, up to date of

attainment of 58 years, as the date of option for commencement of early pension. In the absence of any option, date of receipt of

claim application in Form 10-D may be taken as option date.

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It has been observed that beneficiaries are not well versed

with the filling up of forms resulting in delay in disbursement of pension. In order to avoid delay and sufferings to the

employees/labourers, it is suggested that the following points be kept in view by the Zonal /RO/District Offices before forwarding the

pension applications to the CPF Division at Headquarters (in respect of members/ex-members who have attained 58 years of

age/expired on or before 28.02.2006 and expected to be received by respective Zonal Offices in respect of members/ex-members

who have attained 58 years of age /expired on or after 01.03.2006 except for East Zone till the separate Code No. is allotted):-

1) The complete particulars of the member as given in Form

10-D be mentioned clearly like his name, father’s/husband’s name, sex marital status, date of birth

etc. and the same must tally with the records of FCI.

2) Correct CPF No. and EPS No. should be indicated clearly.

3) The complete address of the office where the employee

was last working should be given.

4) The actual date of leaving service if applicable should be mentioned.

5) The complete details of claimant/nominee should be given.

6) Permanent address along with PIN Code No. should be

mentioned.

7) The member is required to furnish the details of his/her nominee. He can nominate his/her spouse or any of the sons or daughters. A married member, who is not

survived by any member of his/her family or is bachelor/spinster, he/she may nominate a person of

his/her choice to receive the pension.

8) The list of surviving family members of the member covering his/her spouse and all children below 25 years of

age should be furnished. The particulars of Guardian should be given in respect of each minor child, as on the

date of application. In support of the age of children, age proof certificate issued by the School or Municipality/Village

Panchayat (B.D.O.) should be enclosed.

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9) Applicant being other than the member, the date of death

of the member should be mentioned. A death certificate should be enclosed in original along with photo copy of the

same in triplicate.

10) The details of saving bank account No. where the member desires to receive his pension should be given:

a) In case of outstation members other than Delhi, bank

account may be opened in any nationalized bank prescribed by the RPFC from time to time (in

consultation with the local RPFC).

b) Delhi based member may open bank account in any of the designated banks at Delhi approved by RPFC

viz. HDFC, SBI, PNB, Indian Bank, ICICI Bank etc.

(prescribed by local RPFC).

11) Whenever pension is opted from a place beyond the jurisdiction of the Region in which the member was last employed, he should ascertain the name of the designated bank in that other Region and open a saving bank account

there.

12) The following list of documents should invariably be enclosed along with the application form :

EPS Check list for Retirement cases:

Details/Documents to be submitted:

1. Form 8 i.e. year-wise contribution made by the member from the date of entitlement to the date of retirement. (Reason for

non-contribution, less- contribution has to be specified). Contribution for the period 1980-81 to 1994-95 have to be mandatory fill up the Zonal Office and for contribution for the period 1995-96 to 2005-06 print out (duly signed and

stamped) of the Form 8 PS submitted by the Zone to RPFC

should be enclosed.

2. Form 7 for the last two years (i.e. month wise contribution made by the member in the last two years.) (Reason for non-

contribution, less- contribution has to be specified).

3. Birth certificate of member. Documents which can be treated as proof of date of birth is as follows:-

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a) Where date of birth available on the record of the PF Office.

The date of birth indicated in Form 3 (PS) or 4 (PS).

b) Where date of birth is NOT available on the record of

the PF Office .

In this situation the PF office require proof of age of the member shown in the claim form; and this proof/corroboration can

be in the form of certificate of age issued by a School/Municipality/Village Panchayat (B.D.O.).

c) Date of birth of children.

i) A member mentions date of birth of his children the first table of Part-B of nomination form. Where this form

stands pre-filled in the PF office and the date of birth shown in the claim form tally with that shown in nomination form, in that case the date of birth is accepted by PF Office without asking for proof/corroboration in that

behalf. ii) But, where the said nomination form is not on the record of

the PF Office, proof/corroboration in support of the date of birth shown in the claim form 10-D is invariably asked for-

which can be in the form of certificate of age issued by a School/Municipality/Village Panchayat (B.D.O.) which must

be appended to the claim form.

4. Form 10 D in duplicate to be filled by member only. 5. Joint photograph of member and spouse in 4 copies.

6. Full Banking details where pension will be sent, such as Name

of the Bank, Branch name, Address of the Bank Branch, Bank Account Number should be provided. (All the recipients have

to open a separate account in the same bank branch for this purpose).

7. If there is any change in name, the copy of the notification

published or Affidavit duly signed by the Ist Class Magistrate should be enclosed.

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EPS Check list for Death cases:

Details/Documents to be submitted:

1. Form 8 i.e. year-wise contribution made by the member from

the date of entitlement to the date of death. (Reason for non-contribution, less- contribution has to be specified).

2. Form 7 for the last two years (i.e. month wise contribution made by the member in the last two years.) (Reason for non-

contribution, less- contribution has to be specified). 3. Birth certificate of member. Documents which can be treated

as proof of date of birth).

a) Where date of birth is available on the record of the PF

Office.

The date of Birth indicated in Form 3 (PS) or 4 (PS).

b) Where date of birth is NOT available on the record of the PF office

In this situation the PF office require proof of age of the member shown in the claim form; and this proof/corroboration can

be in the form of certificate of age issued by a School/Municipality/Village Panchayat.

c) Date of birth of children.

i) A member mentions date of birth of his every child in the

first table of Part-B of nomination form. Where this form stands pre-filled in the PF office and the date of birth

shown in the claim form tally with that shown in nomination form, in that case the date of birth is accepted by PF Office without asking for proof/corroboration in that behalf.

ii) But, where the said nomination form is not on the record of

the PF Office, proof/corroboration in support of the date of birth shown in the claim form 10-D is invariably asked for-

which can be in the form of certificate of age issued by a School/Municipality/Village Panchayat which must be

appended to the claim for.

4. Death certificate (One copy in original and 3 photocopies.)

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5. Form 10 D (Separate form 10 D each for Widow/ Widower and

for each children who are more than 18 years and below 25 years of age as on the date of death or date of application

which ever is later. For minor children, no separate form 10D is required but a joint photo (photo of widow/widower and

children) of children below 18 years of age as on the date of death or date of application whichever is later is to be

furnished.

6. Non-remarriage, self certificate from the widow/widower.

7. Separate passport size photograph (4 copies each) of each of the children who filled up Form 10 D only. Joint photographs

of widow/widower and children below 18 years of age as on date of death or date of application whichever is later.

8. Full Banking details where pension will be sent, such as Name of the bank, Branch name, Address of the Bank Branch, bank

Account No. should be provided. (All the recipients have to open a separate account in the same bank branch for this purpose).

9. If there is any change in name, affidavit executed before a Ist Class Magistrate has to be submitted, duly notifying the

change in name.

10. Revised form 2 meant for nomination and declaration to be given if pension is claimed other than family member (family

member consist of spouse and children)

11. Guardianship certificate in case of minor children to be obtained from first class Magistrate under Guardianship and Ward Act.

13. The priority for release of pension is as follows:-

1st priority Family**

2nd priority Nominee 3rd priority dependent parents

a) Father

b) Mother

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**Family means:-

(i) Wife, in case of male member of Employees’ Pension

fund (ii) Husband, in the case of female member of Employees’

Provident fund.

(iii) Sons and daughters of a member of Employees’ Provident fund.

Explanation: - The expression ‘sons’ and ‘daughters’ shall include

Children legally adopted by the member.

14. For death cases pension will be paid to widow/widower plus first two children below twenty-five years of age in the

order of age as on the date of death. Pension will be paid till

the last of the children attains the age of 25. This rule is applicable for both death during service and death after

retirement. Orphan Pension:

In case of remarriage the children of the deceased if below 25 years of age will get orphan pension irrespective of remarriage of

the Widow/Widower. Documents submitted by unit offices should be routed through

respective Zonal Offices duly attested/verified by the authorized

officers, in case of members who have attained of 58 years of age or have died on or before 28.02.2006 to Headquarters. However,

the claims by members/ex-members/legal heirs of deceased member (s) be submitted to their respective Zonal Offices in case the date of event falls on or after 01.03.2006

If the service rendered is less than 10 years, then documents

required are as under:-

1. Form No. 7 & 8.

2. Form 10-C (Withdrawal).

3. Bank account No. with full details.

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A certificate to the effect that all the above points have

been taken care of and all the requisite documents are in order, be enclosed to the claim papers by ZO, in absence of which, the

application will be returned to the respective Zonal Office.

The above guidelines be strictly adhered to for smooth processing of pension claims of the employees by RPFC. You

are requested to bring the check-list to the notice of all the units under your control.

Yours faithfully,

CHIEF GENERAL MANAGER (CPF/GPF)

Copy to:

1. All Executive Directors(Hqrs) 2. DGM (pension), FCI, Headquarters, New Delhi. 3. Assistant General Manager (E-I), FCI, Headquarters, New

Delhi. 4. Assistant General Manager (E-II), FCI, Headquarters, New

Delhi. 5. Deputy General Manager (Coordination), FCI, Headquarters,

New Delhi……………….with the request to publish the same in FCI Gazette.

6. Director, Institute of Foodgrains Management, FCI, Gurgaon. 7. CPF-I to VII (Local).

8. All representatives of the Trustees.

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Supplied Free of Cost Serial No._________

For Office use only Inward No.

EMPLOYEES PROVIDENT FUND ORGANISATION Form No.10-C (E.P.S.)

EMPLOYEES’ PENSION SCHEME, 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’

PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL

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(s) _____________________

c) “Family/Legal heir can prefer the withdrawal benefit

claim in case of a member, who attained the age of 58 years before completion of 10 years of eligible service

and died thereafter without claiming the said benefits”.

2. Date of Birth

3. Fathers’ Name__________________________ Husband’s Name________________________

(if applicable) 4. Name & Address of the Establishment in which,

the member was last employed________________ 5. Code No. & Account No. Region/SRO Code

Estt. Code No. A/c No.

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6. Reason for leaving service___________________________

& Date of leaving __________________________________

7. Full Postal Address:- (in Block Letters)_______________________PIN__________

Sh./Smt./Km.______________________________________ S/o, W/o, D/o____________________________________

8. Are you willing to accept Scheme

Certificate in lieu of withdrawal benefits

Yes (a) No (b)

9. Particulars of Family (Spouse & Children & Nominee)

Name Date of Birth Relationship Name of the

With Member guardian of Minor

______________________________________________________ a) Family Members

b) Nominee

10. In case of death of member after attaining the age of 58

years without filling the claim :-

a) Date of death of the member_____________________

b) Name of the Claimant (s) and relationship with the members:____________________

11. MODE FOR REMITTANCE [PUT A TIC IN THE BOX AGAINST

THE ONE OPTED]

a) By postal money order at my cost to

Address given against item No.7

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b) 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 letters)

Branch_______________________________________ (in block letters)

Full Address of the Branch

(in block letters)

12. Are you availing pension under EPS-1995?

If so, indicate:

PPO No._______________ By whom issued _________

Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY

KNOWLEDGE

Date __________ Signature of left Hand Thumb impression Of the Member/Claimant (s)

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ADVANCE STAMPED RECEIPT

(To be furnished only in case of B above) Received a sum of RS.____________________________________ (Rupees_______________________________________________

_______________________________________only) from Regional Provident Fund Commissioner/Office-in-Charge of

Sub-Regional Office_______________________ by deposit in my saving Bank A/c towards the settlement of my

Pension Fund Accounts.

[The space should be left blank which shall be filled by Regional

Provident Fund Commissioner/Office-in-Charge] Rs. 1/-

Revenue Stamp

Signature & Left hand thumb impression of the member on the

stamp

Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.

The details of wages and period of non-contributory service of the member are as under:- Form 3A/7 (EPS) enclosed for the period for which it was not

sent to employees’ Provident Fund Office). (Wages + A) as on 15.11.1995 (if applicable)

Wages as on the date of exit Period of non contributory Service

Year/Month No. of days

Date______ Signature of Employer/authorized Official

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(FOR THE USE OF COMMISSIONER’S OFFICE)

(Under Rs._____________________________________ P.I. No.____________________M.O./Cheque

Passed for payment for Rs.___________________ (in

words) _________________________________________________

_________________________________________________

M.O. Commission (if any) ___________________net amount to be paid by M.O.___________________towards withdrawal

benefit.

D.H. S.S. A.A.O.

(FOR USE IN CASH SECTION)

(Paid by inclusion in cheque No.___________________Dated_____________Vide Cash

Book (Bank) Account No.10 Debit item No.______________________

D.H. S.S. AC (A/cs) ________________________________________________ For issue if S.S., IDS is enclosed.

D.H. 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.

D.H. S.S. A.A.O./APFC (PENSION)

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(Supplied Free of Cost)

EMPLOYEES PROVIDENT FUND ORGANISATION

EMPLOYEES’ PENSION SCHEME, 1995

Form No.10-C (E.P.S.)

Form for claiming withdrawal benefit/scheme certificate

INSTRUCTIONS Who can apply? 1. A member of the Employees’ Family Pension Scheme, 1971

Employees’ Pension Scheme, 1995.

a) Who has left the employment before completion of 10 years service.

b) Who has attained the age of 58 years before completion of 10 years service.

2. A member, who has completed 10 years service on the date

of his leaving the service and has not attained the age of 50 years on the date filling this application or has attained the

age of 50 years on the date of filling this application or has attained the age of 50 years of more but less than 58 years,

and not willing for reduced pension.

Note: 1 To determine the period of 10 years service rendered from 1.3.1971 to 15.11.1995 (if any), shall also be

taken.

Note: 2 (i) A member who has completed 10 years service

and attained the age of 58 years, whether in service or not, is eligible for Monthly Member Pension.

(ii) A member, who has completed 10 years service

and also attained the age of 50 years is eligible to draw pension at reduced rate, after leaving the employment.

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(iii) A member who has left the service on account of

total and permanent disablement, irrespective of his age and period of service, is eligible for monthly disablement

pension.

(iv) To claim the Monthly pension, application in form 10-D should be submitted.

3. Type of benefit eligible

A member falling under item above is eligible to get the

amount towards withdrawal benefit. However, a member falling under item 1 (a) above is advised to opt for the Scheme

Certificate on account of following advantages:-

(i) On taking up employment in another establishment, his earlier service period will be carried forward and clubbing both the spells together pension entitlement shall be regulated.

(ii) If the member does not take up employment and dies before attaining the age of 58 years. His

family will get Family Pension. On his survival, he will get withdrawal benefit with weightage as

may be prescribed. (iii) While availing a Scheme Certificate, there is no

bar to withdraw the P.F. accumulations by the member.

4. Guidance for filling the application:

(S. No. given below refers to the one given in the

application)

Sl. No. 1 (a) Write your name in CAPITAL Letter as given in the

service records or your establishment.

1. (a) To be furnished only when the application is preferred by a person other than the member himself

(i.e. Nominee/family member).

2. (b) The exact date of birth of the member should be given.

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3 to 7 Particulars should be written without any overwriting or

cutting. Correction if any, be attested.

8. The option is to be given by the member only if he has not rendered 10 years service and eligible for

withdrawal benefit.

9. Complete particulars of nominee and family (spouse and all children) should be given without fail.

10. To be furnished when the claim is preferred by nominee

or the family member(s).

11. To be completed only when a member is eligible for withdrawal benefit and opted for it in lieu of scheme

Certificate (not applicable to those who are entitled for

Scheme Certificate or opted for Scheme Certificate in lieu of withdrawal benefit).

12. In case, the member is drawing Family Pension/Pension under the Employees’ Pension Scheme 1995, the details should be furnished.

Advance Receipt.

To be given where the withdrawal benefit is admissible and

opted for payment by cheque. (The Advance Receipt need not be signed by member, if the payment is opted through Money order).

Attestation of claim form

The claim should preferably be attested by the employer under whom the member was last employed.

If for any reasons, the claimant is unable to get the

application attested by his ex-employer, he may forward the claim to the Provident Fund Office duly clarifying the position, after

getting it attested by any one of the following authorized officials:-

(i) Manager of the Bank where the member is holding an account;

(ii) Head of Education Institution; (iii) A Gazetted Officer;

(iv) Sub/Post Master; (v) The Magistrate;

(vi) Member of Central Fund or Regional

Committee;

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(vii) Chairman/Secretary/Member of the

Municipal/District/Local Board; (viii) President of the village

Union/Panchayat/Member of Parliament/Member of legislative Assembly;

(ix) Any other officer approved by the Regional P.F Commissioner.

5. For further guidance/clarifications required, if any,

the Public Relation Officer in the nearest Provident Fund Office (including Provident Fund Inspectorates)

may be contacted.

******************

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(Supplied Free of Cost) Serial No._________

EMPLOYEES PROVIDENT FUND ORGANISATION

EMPLOYEES’ PENSION SCHEME, 1995

Application for Monthly Pension

Form No.10-D (EPS)

Note: To be submitted in two Copies in case pension is to be drawn in other Region.

EXPLANATORY NOTE FOR THE APPLICATION Serial No. given below relates to the corresponding No. given in the application.

1. By whom the pension is claimed?

Indicate any one of the following under Sl. No.1.

Member Widows Widower

Major Orphan

Guardian Nominee

2. Type of Pension Claim – Indicate any on of the following :

a) On attaining 58 years whether Superannuation pension in service or not.

b) Attained the age of 50 years but Reduced Pension below 58 years and left service. c) DISABLEMENT PENSION d) Widow and children pension e) ORPHAN PENTION f) NOMINEE PENSION

3. 4 & 5/ (a) to (e) 4 & 5/Please furnish the particulars

relating to the member correctly.

6. Indicate the actual date of leaving service.

This need not be filled by a member who has attained 58 years and continued to be in service. Indicate “Still in service”.

7. If the reason for leaving service was on account of total and

permanent disablement, as indicated by the establishment to the

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P.F. Office through form 10, then only the member is entitled for

Disablement Pension. In all other cases the actual reason for leaving service may be given. However, a member who continues

in services beyond the age of 58 years may indicate “still in service”.

8. If the present address is temporary one, also indicate permanent address.

9. Sl.No.9 is applicable only to a member of the Pension

scheme and not for his family. The applicant is eligible to commute up to a maximum of 1/3 of his pension so as to

receive 100 times of the pension commuted. If a pensioner who is getting and original pension of Rs.600/- commutes 1/3

of it, he will get Rs.20,000/- as commuted value. The

commutation will be effective only from 16.11.1998. the applicant may give his option for commutation in the

application and this will be effective and paid only if the member – pensioner continues to draw his pension as on 16.11.1998.

On opting for commuted value of pension, the original pension mentioned for Return of Capital will be the balance of

pension after commutation.

10. The member can give his option for return of Capital. Option once exercised is final. He may choose any one of the

following and indicate the number shown under alternative against Sl.No. 10 of the application.

Alternative Quantum of Pension

Return of Capital

1. 90% of original On member’s death 100 times the

original monthly pension to nominee.

2. 90% of original pension to member. On his death 80%

pension to Widow/Widower

On death or remarriage of Widow/Widower whichever a earlier.

90 times of original pension to

nominee.

3. 87.5% of original pension for

a fixed period of 20 years to member. On his death before

20 years, nominee will get pension for balance period.

At the end of 20 years, 100 times of

original pension to member, if he is alive, otherwise to nominee.

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11. The member is required to furnish the details of his/her

nominee for receiving the Return of Capital. A member can nominate his/her spouse or sons or daughters. A married

member who is not survived by any member or his family (spouse/sons/daughters) and a bachelor/spinster may

nominate a persons of his/her choice to receive the Return of Capital/Pension due if any, under Alternative 3 as per Serial

Number 10 above.

12. This should be completed by the member. In his absence, by the spouse/children. The list of surviving family

members of the member covering his spouse, all children should be furnished. The particulars of Guardian should be

given in respect of each minor child, as on the date of application. In support of the age of children, age proof

certificate obtained from the School or Registrar of Birth-

death or E.S.I. Record, or Municipal authorities should be enclosed. In the case of Guardian other than natural

guardian, a Guardianship Certificate should be enclosed.

13. Applicable only in case the member is not alive. In support to the date of birth, Death Certificate should be

enclosed.

14. The details of Saving Bank Account Number should be given.

In case the claim is preferred by spouse, he/she should give

his/her Saving Bank Account Number and also separate Saving Bank Account Numbers. In respect of each child Saving Bank

Account Numbers of children who are below the age of 25 years (as on date of Death of member) should be given. On behalf of minor child, Saving Bank Account opened in the name of minor

and operated by the guardian of the minor and Account Number should be given.

Pension is payable through any branch of the *PNB/SBI on

the specified day of each month by credit to the Saving Bank Account of eligible pensioners. Hence, Saving Bank Account

should be opened only in the said Bank. Necessary guidelines have been given to all branches of Bank to open a Saving Bank

Account for the pensioners. The applicant may approach any branch of the said bank to open the account.

The member, spouse and children (minor or major) should

necessarily open Saving Bank account in the same branch of the

Bank.

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Whenever pension is opted from a place beyond the jurisdiction of the Region in which the member was last employed, he should

ascertain the name of the designated bank applicable in that Region and open a Saving Bank Account therein.

On sanction of pension, intimation will be sent to the pensioner

to contact the bank/Post Office.

14 (A) In case of death of the member before attaining 58 years without leaving any eligible family members to receive the

pension, the nominee as appointed by the member through the Form 2(Revised) already sent to the P.F. Office may apply giving his

particulars against this column.

15. In case the member was working in different establishments and obtained Scheme Certificate, the details should be furnished

against this column. In case, no Scheme Certificate was received or not applied for the same, the details or past employment may be indicated in this column.

16. If the applicant is already receiving pension under Employees Pension Scheme, 1995 or claim Pension, the details should be

furnished against the column.

17. List of documents to be enclosed and specified under column No.17:

a) Descriptive role of pensioner and his/her specimen signature/thumb impression in duplicate;

b) 3 Passport size photographs (if claimed by the member Joint photo with spouse), if the pension is claimed by member,

there is no need to send photograph of the children, If claimed by widow, the photograph should be sent for widow/widower and

his/her two children (below 25 years) separately. The photograph are to be attested by the employer or his authorized officer,

indicating the pension to whom the photograph relates and also the P.F Account Number of the member, written on the reverse and

placed in a separate envelope.

c) In the case of a member, who is permanently and totally disabled during the employment, he /she should undergo a

Medical Examination before the Medical Board as advised by the

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E.P.F. Office, However, the disablement should occur while in

employment.

d) The application should be forwarded through the establishment in which the member last served/died. The

establishment should furnish the certificate and wage particulars duly attested by the authorized officer.

e) Only if the establishment is closed, the application

should be forwarded through the Magistrate/Gazetted Officer/Bank Manager/any other authorized officer as may be approved by the

Commissioner.

*****************

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Supplied Free of Cost Serial

No._________

For 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?

2. Type of Pension Claimed.

3. (a) Member Name :

(in Block Letters) (b) Sex :

(c) Marital Status :

(d) Date of Birth/Age : (e) Parents/Spouse Name :

4. E.P.S. Account Number

RO

SRO

Establishment

Code No.

Member A/c

No.

5. Name & Address of the Establishment In which the member was last employed :

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6. Date of Leaving Service :

7. Reason for Leaving Service :

8. Address for Communication :

PIN………………………………..

a) In case of Reduced Pension( Early Pension)

Date of Option for commencement of pension

Date Month Year

Member can exercise option in case of early Pension indicating the date of option for commencement of pension:

• Date of exit from service (on completion of 50 years)

• Date of filling the Form 10 D

• Date of between the date of exit (on completion of 50 year)

and date of completion of 58 year (Superannuation age)

9. Option for commutation of 1/3 of Quantum

Pension (if option is for lesser

Commutation indicate the quantum Yes No Amount

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10. Option of Return of Capital

(Please refer Serial Number 10 of INSTRUCTIONS)

[Put a Tick (√)]

Yes No

If yes, indicate your choice of alternative

√ 1 2 3

11. Mention your Nominee for Return of Capital

Name :

Relationship :

Date of Birth : Address :

12. Particulars of Family

Sl.No.

Name Date of Birth/Age

Relationship with Member

Indicate against minor

Guardian Name

Relationship with member

(1) (2) (3) (4) (5) (6)

Note: If any child is physically handicapped, please indicate “DISABLED” below the name

26

13. Date of death of Member (if applicable)

14. Details of Saving Bank Account Opened

a) Name of the Bank/Address:

ii) Name of the Branch: iii) Full Postal address:

Pin Code……………………

Pensioners may at their discretion opt to a draw pension either from the designated Post Office or from

designated Bank.

Sl. No. Name of the Claimant (s) Saving Bank Account No.

14A. If the claim is preferred by nominee.

Indicate his/her

i) Name:

ii) Relationship with the deceased Member:

15. Details of Scheme Certificate already in possession of the Member, if any.

Scheme Certificate received & enclosed

27

Not received

Not applicable

If received, indicate:

Sl.No. Scheme Certificate Control No. Authority who issue the Scheme Certificate

16. If pension is being drawn Under E.P.S., 1995

PPO No. issued by

RO SRO

17. Documents enclosed (Indicate as per the instructions)

1. 2.

3. 4.

5. 6.

7. 8.

9. 10.

28

TO BE SUBMITTED IN DUPLICATE IN RESPECT OF EACH PERSON ELIGIBLE FOR PENSION

Descriptive role 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 :

(1)……………………………………………………

(2)……………………………………………………

10. Specimen Signature of Pension :

(1)……………………………………………………

(2)………………………………………………………

(3)……………………………………………………

29

11. (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:-

a. I am not drawing Pension under Employees’ Pension

Scheme, 1995.

b. The particulars given in this application are true and

correct.

Signature of the applicant

Left hand Thumb Impression

30

(TO BE FILLED IN BY THE EMPLOYER AUTHORIZED OFFICER OF THE ESTABLISHMENT)

Certified that:

i) The particulars of the members are correct.

ii) The particulars of Wages and Pension Contribution for the period of 12 months preceding 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).

i. Documents as given in the Instructions.

ii. Form of descriptive roll and specimen signature.

Signature of Employer/Authorized Official of The Establishment with Seal & Date

Year Month Wages Pension Contribution

due

Details of period of non-contributory service.

If there is no such period, indicate ‘Nil’

No. of Days Amount Year No. of days for which no wages were earned

(1) (2) (3) (4) (5) (6) (7)

31

(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 S.S. A.A.O. A.P.F.C. Date date date date

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 S.S. A.A.O. A.P.F.C. (PENSION) Date date date 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 S.S. A.A.O. A.P.F.C. Date date date date