.

erial No:

Form No, J() C (E,P.s)

EMPLOYEE' PE 10! SHE 1E, 1995

FORM TO BE USED BY A l1-'fEMBER OF THE Ej~IPLOrEES' PENSION SCHEME,

1995 FOR CLAIMING WITIJDRA WAL BENEFITI..W:IIEME CERTIFICATE

(Rcmf the instructions before filling lip this form)

I. a) Name ofthc member :-

( In Block Letter ,)
b) Name orlhc claimant (s)

2. Date Of Birth

a) Father" _ I arne

b) Husband's arne
(If applicablej

4, Name & Addre' ofthc Establishment Tata onslIltancy Services Limited

in which. the member wa . la 't employed fh
IO Floor, Air I~dia Iluilding,
Narinlll Point, Mumbai - 400021.

5. ~~ ..a.. II l' 10
Code No. & A count No. MHIB '/48475/ _

6. Reason far leaving ~cn'iccs

& Dale of leaving

7. Full Postal Address :-

(In Block Letters)
hi mt./Km
10. W/o. 0/0
------------------
____ pI, _

,~ob rJ~. }-
~\) ~ .....
 8. Are you willing to accept'cheme
(a
(o)
Certificate in lieu of withdrawal bcnefil';
Yes 0 o

9. Particulars of Family (Spouse & Children & , ominee)

lame Date of Birth RelHtionshi With tv1ember

(a) Family
Members

(b) ominee

ote:-J..lfopting for cherne Certificate, please provide age proofs of Children.

2. Withdrawal benefits arc not payable if opted for Scheme Certificate.

10. In case of death of membcr after attaining the age of 58 years without filling the claim:-

(a) Date of death of the member:

(b) ame of the Claimant(s)! and relationship with the members:

II. MODE FOR REM rrrA i CE (I' T A TIC IN THE BOX AGAI 1."1''1'1 IE 0 E OPTED]

(a) By postal money order at m}' cost to addrcss given against item NO.7

(b) A ount payee cheque sent direct for credit to my SB Ale ( "cheduled Bank) under
intimation to me;
1
. B. Accounts j o. :.J
Name of the Bank ---_ ... ~-_._._----
(in block Ictters)
Branch
(in block letters)
Full Address Of the Brdnch
12. Arc your availing pension under EP5-95'1
Ifso indicate pro NO... By Whom issued _

Certified THAT TIlE PARTl Li\RS ARE TRUE TO TilE BEST OF MY KNOWLEDGE.

Date:
~~ ~e-
Signature or left hand thumb
I In pression of the mem ber/c1aimant
 AD AJ 1 E STAMPED RECEIPT
ITo be furnished only in casc of (h) abovcl

Received a sum of Rs (Rupees " , , .. , , , )

Only from Regional Provident Fund Commissioner / anicer-in charge of Sub-Regional
Office
---------
By deposit in my saving Bank Ale: towards the senlement of my Pension Fund Account,

(The pace houJd be len blank which shall be filled by Regional Provident Fund Commissioner IOfficcr-
in- harg')

'ignalure & left hand thumb impression of the member on the 'lamp

el1ified that the particulars orthe member given arc correct and the member has signed/thumb impre sed
before me.

The detail of wages an'd period of non-contributory service of the mcmber are as under:-
Form 3A17 (EP ) endo ed for the period for which it was not sent to employee's Providcnt Fund Office)

Wage (Basic + D.I\) as on 15.11.950f applicable)

Wage' a. on the date of e, -it

Period of non contributory Service

Y car/Month NO.of day'

Tata Consultancy ,'en'ices Limited.

Authorised Sign:ltory
 (FOR THE USE OF COMJ1I1JSSIONER'S OFFICE)

(Under Rs .
P.1. 0 '" "'1. o.le hcquc

Passed for payment /()r R (in \vords) .

... .. ... ... ........ .. . .. .. .. ... .. .. .
M.O. Cornmis ion (irany) ncl ,unount to be paid by M.O .

D.H.
5.S.
A.A.O

(FOR USE I. C1S1I SECTION)

Paid. by mclu
. '. III c hequc N 0........................
Ion [)t vide ea..h Book (Bank)
. Account
o. 10 Dcbit item No .

D.H S.S AC(A/cs)

For issue irS. ;. IDS is cl1clo cd.

D.H. 5.5. A.A.O/APFC( cs)

(FOR E IN PEN,10' EeTION)

eheme Ccrti ficate bearing the control No . ..1 'sued 011 .................. and
entered in the scheme Certificate Control Rcgister-

D.H. S.S A.A.O

A.P.F.C. (pENSION)