EMP ID:-

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

EMPLOYEE’S PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEE’S 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 _____________________________________________
(Same as above)

2. Date of Birth (DD-MM-YYYY)

3. a) Father’s Name _____________________________________________

b) Husband’s Name _____________________________________________

(if applicable)

4. Name & Address of the ICICI Prudential Life Insurance Company Limited
Factory / Establishment in ICICI Prulife Towers, 1089, Appasaheb Marathe Marg,
Which the member was Prabhadevi, Mumbai – 400 025.
last employed

5. Code No. & Account No MH/ BAN

MH / BAN / 49598
/ 49598 / /
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 _____________________________________________

8. Are you willing to accept Scheme
Certificate in lien of withdrawal benefit Yes X No 
9. Particulars of Family (Spouse, Children’s & Nominees)
Date of Relationship with Name of the Guardian for
Name Birth Member minor

(a) Family ________________________________________________________________________

Member ________________________________________________________________________

____________________________________________________________________
(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 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 N/A
b) By Account Payee cheque sent direct for credit to my S.B a/c (Scheduled Bank)
Under intimation to me 
S.B Account No. _____________________________________________

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 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

to-wards 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 employee’s 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
 (FOR THE USE OF COMMISSIONER’S 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 Register-

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

 CHECKLIST:
Please find below documents required for submitting Pension
forms separately. (* marked are mandatory).
 Aadhaar Card copy*.
 Pancard copy*.
 Original Cancelled cheque* (with name on it),
Passbook copy (If no name on Original Cancelled cheque).

 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

• Kindly provide a “ORIGINAL CANCELLED CHEQUE” with your name printed

on the cheque & also zerox copy 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 AS IT GETS FREEZED/CLOSED
AFTER THREE MONTHS. Please ensure name in cheque and form is same.

• Your name in form should be same as per your cheque details.

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.

• Point No.9, 10, & 12 – Please leave it blank

• Signature on bottom of the Page 2. Fix revenue stamp & signed across on
• Page 3 & keep all the details blank
• Page 4 please keep it blank
___________________________________________________________________
Address for sending the pension withdrawal form:
ICICI Prudential Life Insurance Company Ltd,
Shared Services - HR Ops (PF Team)
Upper Basement, Unit No.1A & 2A, Raheja Tipco Plaza,
Rani Sati Marg, Malad - East, Mumbai - 400 097.
___________________________________________________________________