Steps for filling Pension Withdrawal form Mention your Employee Code on top of the Pension Withdrawal Form

m You are requested to clearly mention all the details in BLOCK LETTERS from point no.1 to point no.3 Point no 4,5,6 leave it blank Point No.9, 10, & 12 Please leave it blank Point no.11 please mention the complete Bank branch address It is Mandatory to attach ORIGINAL CANCELLED CHEQUE along with the Pension withdrawal form pertaining to any of the saving Bank account number mentioned on point no 11 or else the form will get rejected by the Regional Provident Fund Commissioner . Signature on bottom of the Page 2 where (X) is marked . 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:

o ICICI Prudential Life Insurance Company Ltd,

o Shared Services - HR Ops ( PF Team)

o Grd Floor, Vinod Silk Mills Compound, Ashok Nagar, o Chakravarti Ashok Road, Kandivali - East, Mumbai - 400 101

EMP ID:-

FORM 10 C PENSION

Group No._____________ At _____________ Serial No. _____________ Inward No._____________ For Office Use Only FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Read the instructions before filling up this form)

EMPLOYEES PENSION SCHEME, 1995

1. a) Name of the member

(In Block Letters) b) Name of the claimant

__________________________________________ First name Surname _________________________________________ First name Surname __________________________________________ _________________________________________ First name Surname _________________________________________

2. Date of Birth( DD-MM-YYYY) 3. a) Fathers Name

b) Husbands Name (Only incase of married female)

4. Name & Address of the

Factory / Establishment in Which the member was last employed

ICICI Prudential Life Insurance Company Ltd ICICI Prulife Towers, 1089, Appasaheb Marathe, Prabhadevi, Mumbai 400 025

5. Code No. & Account No 6. Reason for leaving service & Date of Leaving

MH / BAN / 49598 /
Resigned _________________________________________

7. Full Postal Address (In Block Letters) House no/Room no/Bldg no

______________________________________ ______________________________________

Street No./Area/PO
_______________________________________

State & Pin Code Number

______________________________________

8. Are you willing to accept Scheme Certificate in lien of withdrawal benefit

Yes

No

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

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

(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 X

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. (Mandatory to attach a cancelled cheque along with the form) Name of the Bank (In Block Letters) Branch (In Block Letters) Full Address of the Branch (In Block Letters) ____________________________________ ____________________________________ ____________________________________ ____________________________________ _____________________________________ _____________________________________ _____________________________________

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 Date: _________________ Signature or Left Hand

____________________________ (X) 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-incharge 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 given are correct and the member has signed / thumb impressed before me. The details of wages and the period of non-contributory services 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 services Year / Month _______________________ days ______________________ Date: _________________________ Signature of the Employer / Authorised Official

(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 eclosed

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)