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Option for Return of Capital (Please refer: Serial Number 10 of Instrctions)
| :
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Yes
No
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| 11.
| Mention your nominee for return of capial
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| ..................................................
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| Name
| :
| ..................................................
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| Relationship
| :
| ...................................................
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| Date of Birth
| :
| ...................................................
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| Address
| :
| ...................................................
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| 12.
| Particulars of Family
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Sl.No.
Name
Date of Birth/Age
Relationship with member
Indicate against minor
Guardian's name
Relationship with member
(1)
(2)
(3)
(4)
(5)
(6)
Note.-If any child is physically handicapped, please indicate "Disabled "
below the name.
13.
Date of death of Member (if applicable)
:
...................................................
14.
Details of Savings Bank Account opened
:
....................................................
(1)Name of the Bank
:
...................................................
(2)Name of the Branch
:
...................................................
(3)Full Postal Address
:
...................................................
PIN CODE..................................
Sl.No.
Name of the Claimant(s)
Savings Bank Account No.
14-A.
If the claim is preferred by nominee, indicate his/her
:
...................................................
(1)(1)Name
:
...................................................
(2)(2)Relationship with the deceased Member
:
...................................................
15.
Details of Scheme Certificate already in possession of the Member, if any
Scheme Certificate received and enclosed
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| Not Received
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| Not Applicable
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SL.No.
Scheme Certificate Control No.
Authority who issued the Scheme Certificate
16.
If pension is being drawn under Employees' Pension Scheme, 1995
:
PPO No. issued
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RO
SRO
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| 17.
| Documents enclosed (Indicate as per the instructions)
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| (1)
| (6)
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| (2)
| (7)
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| (3)
| (8)
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| (4)
| (9)
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| (5)
| (10)
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TO BE SUBMITTED IN DUPLICATE IN RESPECT OF EACH PERSON ELIGIBLE FOR PENSION
Descriptive roll 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's/Husband's Name
:
...................................................
5.
Sex
:
...................................................
6.
Nationality
:
...................................................
7.
Religion
:
...................................................
8.
Height
:
...................................................
9.
Personal Marks of Identification
:
(1) ...........................................
(2). ............................................
10.
Specimen Signature of Pensioner
:
(1). ............................................
:
(2) ............................................
:
(3) ............................................
11. (Only in the case of illiterate Claimant (Pensioner) Left Hand Finger-impression):
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Thumb
Index
Middle
Ring
Small
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Signature.....................................
Place:Name of Attesting Authority...........................
Date:Official Seal:
Certified that:
(i) I am not drawing pension under Employees' Pension Scheme, 1995.
(ii) The paarticulars given in this application are true and correct.
(i) the pariculars of the member 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: