Pf

1. *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
(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) Father’s Name _____________________________________________
b) Husband’s Name _____________________________________________
(if applicable)
4. Name & Address of the ICICI BANK LTD.
Factory / Establishment in ICICI Bank Tower, Bandra-Kurla Complex,
Which the member was Bandra (East), Mumbai – 400 051.
last employed
5. Code No. & Account No
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
X 
MH / 18796 /

2. Certificate in lien of withdrawal benefit Yes No
9. Particulars of Family (Spouse, Children’s & Nominees)
Name
Date Of
Birth
Relationship with
Member
Name of the Guardian of
minor
(a) Family
Member
(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
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 MENTIONED ARE TRUE TO THE BEST OF MY KNOWLEDGE
(X)
Date: _________________ Signature or Left Hand
Thumb impression of the
Member / Claimant
N/A


3. 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)
(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
Re.1/-
Revenue
Stamp

4. MH / 18796 /
(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)

5. 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