*EMP ID:-** *Mobile No.

FORM 10 C PENSION
Group No. _____________ At ____________________ Serial No. ______________ Inward No. _____________ For Office Use Only

EMPLOYEES PENSION SCHEME, 1995 FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE (Pls. read the instructions before filling up this form )
1. a) Name of the member _____________________________________________ (In Block Letters) b) Name of the claimant _____________________________________________ (Same as above)

2. Date of Birth (DD-MM-YYYY) 3. a) b) Fathers Name _____________________________________________ Husbands Name _____________________________________________ (if applicable)

4. Name & Address of the Factory / Establishment in Which the member was last employed 5. Code No. & Account No

ICICI BANK LTD.

ICICI Bank Tower, Bandra-Kurla Complex, Bandra (East), Mumbai 400 051.

MH / 18796 /

6. Reason for leaving service & _____________________________________________

* Date of Leaving (DD-MM-YYYY)

_____________________________________________ 7. Shri / Smt / Kumari _____________________________________________

S/o, W/o, D/o _____________________________________________ Full Postal Address (In Block Letters) H.No./R.No./Building name _____________________________________________ Street No./Area/PO _____________________________________________

Teh/District State & Pin Code Number

_____________________________________________ _____________________________________________ Yes

8. Are you willing to accept Scheme

Certificate in lien of withdrawal benefit

No

9. Particulars of Family (Spouse, Childrens & Nominees)

Name (a ) Family Membe r Date Of Birth Relationship with Member Name of the Guardian of minor

(b )

Nomine e

10. In case of death of member after attaining the age of 58 years without filling the claim: a) Date of death of member: b) Name of the claimant and relationship with the member: 11. MODE OF REMITTANCE (PUT A TICK IN THE BOX AGAINST THE ONE OPTED) a) By postal money order at my cost to the address given against item no. 7 Under intimation to me S.B Account No.

N/A

b) By Account Payee cheque sent direct for credit to my S.B a/c (Scheduled Bank)
_____________________________________________

Name of the Bank (In Block Letters) _____________________________________________ Name of the Branch _____________________________________________ (Mandatory to attach a cancelled cheque along with the form) Full Address of the Branch as per cheque. R.No./Building name _____________________________________________ (In Block Letters) Street No./Area/PO _____________________________________________ Teh/District State & Pin Code Number _____________________________________________ _____________________________________________

12. Are you availing pension under EPS-95? If so indicate : PPO No._________________ By Whom Issue________________

CERTIFIED THAT THE PARTICULARS MENTIONED ARE TRUE TO THE BEST OF MY KNOWLEDGE (X)

Date: _________________

Signature or Left Hand Thumb impression of the Member / Claimant

ADVANCE STAMPED RECEIPT

(To be furnished only in case of (b) above)

Received a sum of Rs. ____________ (Rupees ____________________________________________ ____________________ only) from Regional Provident Fund Commissioner / Officer-in- charge of Sub-Regional Office __________________________________ by deposit in my savings 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 / Officer in charge)

Re.1/Revenue Stamp
(X) Signature or Left hand thumb impression of the member on the stamp

Certified that the particulars of the members given are correct and the member has signed / thumb impressed before me. The details of wages and the 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 the employees Provident Fund Office) Wages (Basic + D.A.) as on 15.11.95 (if applicable) Wages as on the date of exit Period of non contributory service Year / Month __________________ days ______________ Date: _________________________ Signature of the Employer /

Authorised Official

MH / 18796 /
(FOR THE USE OF COMMISSIONERS OFFICE)
(Under Rs.______________________________________ P.I No.____________________________ M. O. / Cheuqe Passed for payment for Rs.._________ (in words) ______________________________________

M. O. Commission(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.

A.P.F.C(A/cs)

(FOR USE IN PENSION SECTION) Scheme Certificate bearing the control No. _______________ issued on _______ and entered in the Scheme Certificate Control RegisterC.C. S.S. A.A.O. A.P.F.C (PENSION)

Steps for filling Pension Withdrawal form

Mention your Employee Code & Mobile Number on top of the Pension Withdrawal Form You are requested to clearly mention all the details in BLOCK LETTERS from point no.1 to point no.7 Point no.11(b) Compulsory, please mention the complete Saving Bank details

Please provide ORIGINAL CANCELLED CHEQUE. If MICR code is not mentioned on the cheque then please also attach Photocopy
of Front Page of Bank Pass Book OR Latest Bank Statement duly attested by Bank Authority along with the Pension withdrawal form pertaining to the Bank account number mentioned on point no. 11(b), DO NOT WRITE SALARY ACCOUNT NO. AS IT GETS FREEZED/CLOSED AFTER THREE MONTHS.

1) Joint Saving Bank Account not acceptable / account should be in single name of member, 2) The Cheque must bear MICR/RTGS/NEFT/IFSC Code or else the same would be rejected.
Signature on bottom of the Page 2. Fix revenue stamp & sign across on Page 3 & keep all the details blank Page 4 please keep it blank Address for sending the pension withdrawal form:

PF Section - Payroll Team

ICICI BANK LTD Trans Trade Centre, 5th Floor, Near Floral Deck Plaza, MIDC, Near Seepz, Andheri ( E ) Mumbai 400 093