Serial No:

 
Emp.code :00

For Office use Only Form 10 – D (EPS)

     
EDP Inward No. & Date (Supplied free of cost)
      
__________________________________________________________________
FORM 10-D (EPS)(PENSION)
    
EMPLOYEES’ PENSION SCHEME, 1995
  , 
APPLICATION FOR MONTHLY PENSION
   
(Read INSTRUCTIONS before filling in this Form)         

1. By whom the pension is claimed? 2. Type of Pension claimed

      ?           
MEMBER SUPERANNUATION PENSION
3. 3. (a) Member’s Name    :
(In BLOCK LETTERS)   
(b) Sex  :

(c) Marital Status   :

(d) Date of Birth/Age : D D M M Y Y Y Y

  /         

(e) Father’s/ Husband’s Name :

 /   
4. 4. EPF Account No. : RO SRO EstablishmentMember’s
5.        Code No. A/c No.
        
UP / 1860
6. 5. Name & address of the Establishment : HINDALCO INDUSTRIES LTD
7. in which the member was last employed P. O. RENUKOOT
         Distt. SONEBHADRA (U. P.)
   PIN : 231217
6. Date of leaving service :
   
7. Reason of leaving service :
   
8. 8. Address for communication :
   

9. Option for commutation of 1/3 of Yes No If yes, QUANTUM

pension (if Option is for lesser      
 Commutation indicate the quantum) 
  /       
  

9. 10. Option for Return of Capital (Please Yes  1 2 3

10. refer Sl No. 10 of INSTRUCTIONS)
11. Put a tick () if yes, indicate your
No  
12. choice of alternative
           
   ()         

13.

11. Mention your Nominee for Return of : NA

Capital      

  
Name  :
Relationship  :
Date of Birth   :
Address  :

12. Particulars of family :  :

Sl. No. Name Date of Relationshi Indicate Against Minor
   birth/age p     
 / with  
Member Guardian Relationship
   Name with
   Member
   

(1) (2) (3) (4) (5) (6)
1. MRS. MALTI DEVI 53 Years WIFE

Note: If any child is physically handicapped, please indicate “Disabled” below the name.
                  

13. Date of death of Member (if applicable) : D D M M Y Y Y Y

               

14. Details of Savings Bank Account :

Opened
    
Name of the Bank    :
Name of the Branch    :
Full Postal address    :
PIN CODE   :

Sl. No. Name of the Claimant/s S. B. A/c No.

        
1
14. (A) If the claim is preferred by
Nominee, indicate his/her
        /
   

14. (B) Name  :

Relationship with the deceased Member : NA
    

15. Details of Scheme certificate already Scheme Certificate

in possession of the member, if any   
put a tick () received & enclosed
   
           Not received 
    ()     
Not applicable 


If received indicate :
      

Sl. No. Scheme Certificate Control No. Authority who issued the scheme Certificate
   -       -  
Not applicable Not applicable

16. If Pension is being drawn under PPO No. Issued by RO / SRO

E.P.S. 1995  /  
       
   

17. Documents enclosed  

(Indicate as per the Instructions)      
1. Descriptive roll of the member with Specimen signature / fingers
impression.
2. Bank passbook photocopy of the member.
3. Photographs of the member
4. Form No.5(P.S.)
5- Form No.7(P.S.)2008-2009,2009-2010.

Certified that ( i) I am not drawing Pension under EPS, 1995

               

(ii) The particulars given in this application are true and correct.
           

Place: Renukoot Signature / Left Hand Thumb

 Impression of applicant
Date: December 7, 2021   / 
     

(TO BE FILLED BY THE EMPLOYER/AUTHORISED 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 pay drawn.)
                       
 

Year Month Wages  Pension Details of period Non-contributory

  Contributio Service. If there is no such period
n indicate “NIL”
Due           
       
No. of Amount  Year No. of days of which no
days   wages were earned
       
    
(1) (2) (3) (4) (5) (6) (7)

Encl.: 1. Documents as given in the Instructions

       
2. Form of descriptive role and specimen signature
      
Signature of Employer/
Authorised Officer of the
Establishment with seal & Date
   /  
      
(TO BE SUBMITTED IN DUPLICATE IN RESPECT OF EACH OF PERSON ELIGIBLE ROR PENSION)
              

Descriptive roll of Pensioner and his/her Specimen signature/Thumb impression

1. Name of the member :

  
2. E.P.F. Account No. :
  
3. Name of the Pensioner :
  
4. Father/Husband Name :
/  
5. Sex :

6. Nationality :

7. Religion :

8. Height :

9. Personal marks of identification :
    

10. Specimen signature of pensioner : 1.

   
2.
3.

11. (Only in the case of illiterate Claimant (Pensioner) Left hand finger impression
            

THUMB INDEX MIDDLE RING SMALL

   

Place  : Signature:

Date  :

(Name of the Attesting Authority )

 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 pleased below for approval.
                   
            
Entered in Form 9/F/3 (PS), Master Ledger Card/Claim Inward Register.
 /F/     /       
Form 2(R) enclosed alongwith the documents furnished by the claimant.

Clark S. S. A. A. O. A. P. F. C. (Pension)
    
Dt. Dt. Dt. Dt.

(FOR USE IN PENSION PRE-AUDIT CELL) ,    
The input data sheet verified with reference to the application and documents and found correct
PPO may be generated through computer.       
                

Clark S. S. A. A. O. A. P. F. C. (Pension)
    
Dt. Dt. Dt. Dt.

(FOR USE IN PENSION DISBURSEMENT SECTION)   

PPO No.  Bank :
Date of issue to the bank      :
Intimation sent to the claimant and also to Accounts Branch on:
……………..        
(Date) 

Clark S. S. A. A. O. A. P. F. C. (Pension)
    
Dt. Dt. Dt. Dt.
NAME OF THE MEMBER :

NAME OF FATHER :

NAME OF WIFE /SON/DAUGHTER :

DATE OF BIRTH :

SEX :

PENSION SCHEME A/C No. :

ADDRESS :

PHOTO GRAPH OF

PHOTO