EMPLOYEES PENSION SCHEME 1995

DETAILS OF BREAK IN SERVICE

Name of the member

Account Number

A) Date of commencement of Family

Pension Fund membership

B) Date from which Family Fund

contribution Recovered

C) Date of commencement of Pension

Fund membership

D) Last date upto which wages were paid :

and contribution recovered
4

Period of Break in reckonable service

(indicate no.of days for which no wages
were paid to the member
Month & Year

Last salary drawn

Pensionable salary

Date

Signature of Employer