Employees' Provident Fund Scheme, 1952

(Refer to instruction) 1. Name of the members in Block Letters: 2. Father's Name or (husband's Name in the case of married woman) 3. Name & Address of the Factory/Establishment in which the member was employed. SPARSH BPO SERVICES LTD. INTELENET TOWER, PLOT CST NO 1406 - A / 28, MALAD (WEST), MUMBAI : - 400 064. 4. Account No : MH / 94723 / Form : - 19

Regn. No.: GR. No. : KANDIVALI - 34

5. Date of leaving service : ________ /___________ / 20_____. 7. Full Postal Address (In Block Letter):

6. Reason for leaving service : RESIGNED.

PIN : 7. Mode of remittance : 8. Put a tick ( ) in the box against the one opted.

a. By Postal Money Order at my ( X ) To the address given against item No. 7 cost. S.B. Account No b. By account payee cheque ( ) Name of the Bank sentDirect for credit to my Branch S.B.A/c (Scheduled Full address of the Branch Bank/P.O.)Under intimation to Contribution for the Current Financial Year. 200 / 200 . A/C. No. : MH / 94723 / MONTH APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Total : Form No. 5. A/C NO.
MH / 94723 /

AMOUNT OF WAGES

WORKER'S SHARE E. P. F.

EMPLOYER'S SHARE
E.P.F DIFF BET 12% & 8.33% IF ANY. PENSION FUND CONT. 8.33

REFUND OF ADVANC

NO.OF DAYS/PERIOD OF NON-CONT SERVICES IF ANY.

REMARKS

NAME OF EMPLOYEE

FATHER OR HUSBAND NAME

D. O. B. SEX

DT OF JOINING THE FUND

TOTAL PERIOD OF PERVIOUS SERVICES AS ON THE DATE OF JOINING THE FUND (ENCLOSED SCHEME CERTIFICATE)

REMARK

Form No. 10. A/C NO.

MH / 94723 /

NAME OF EMPLOYEE

FATHER OR HUSBAND NAME

DT OF LEAVING SERVICE

REASON FOR LEAVING RESIGNED.

REMARK

FOR SPARSH BPO SERVICES LTD. Date: ______ /_____ /20____. AUTHORISED SIGNATORY. Signature of Employer/ Authorised Official.

( information to be furnish ed by the Employer if the Claim Form is Attested by the Employer) Certified that the above contributions have been included in the regular monthly remittances. The Applicant has signed/Thumb impressed before me. FOR SPARSH BPO SERVICES LTD.

X
AUTHORISED SIGNATORY. Signature of Left/Right hand thumb impression of the Member Signature of Employer/ Authorised Official Date: ______ /_____ /20____. Designation & Seal SPARSH BPO SERVICES LTD. Encl. INTELENET TOWER, PLOT CST NO 1406 - A / 28, Declaration of non MALAD (WEST), MUMBAI : - 400 064. employment. In the case of submission of application for settlement under clause (s) of sub - paragraph (i) and in clause (b) of Note: - subclause (b) of sub - paragraph (2) of paragraph 69 of the EPF Scheme, 1952, the claim should be submitted after two months from the date of leaving service provided the member continues to remain unemployed in an establishment to which the Act applies.

Date: ______ /_____ /20____.

Signature of Left/Right hand thumb impression of the Member

ADVANCE STAMPED RECEIPT (To be furnished only in case of 8 (b) above) Received a sum of Rs. Rupees

from Regional Provident Fund Commissioner / Officer -in-Charge of Sub Accounts Office Regional Provident Fund Commissioner / Officer -in-Charge of Sub Accounts Office
The space should be left blank which shall be filled in by Regional Provident Fund Commissioner/Officer -in- Charge of S.A.O.

Affix 1/= Rupee Revenue X Stamp. Signature of Left/Right hand thumb impression of the Member (For the use of Commissioner's Office) A/C Settled in part/Full Entered in F. 21-A/24/219 & withdrawal register. Clerk Section Supervisor P.I.No. Account No. In words M.O. Commission (if any) AOC/APFC Net Amount to be paid by M.0 Date (For use in Cash Section) Paid by inclusion in Cheque No : Date Section M.O./Cheque Passed for payment for Rs.

vide Cash Book (Bank) Account No.3 Debit Item No

HC Remarks.

AC / RC

Form No. 10 C (E.P.S)

EMPLOYEES' PENSION SCHEME, 1995.

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE.

Serial No: Inward No: For Office Use Only

(Read the instructions before filling up this form)

1. a. Name of the members in Block Letters: b) Name of the claimant (s) 2. a. Father's Name. b. Husband Name 3. Name & Address of the Factory/Establishment in which the member was employed. SPARSH BPO SERVICES LTD. INTELENET TOWER, PLOT CST NO 1406 - A / 28, MALAD (WEST), MUMBAI : - 400 064. 4. Code No & Account No : MH / 94723 / 6. Reason for Leaving Service : RESIGNED. 5. Date of Birth: ________ /_____________ / _________. & Date of leaving service : ________ /_____________ / 20_____.

7. Full Postal Address (in Block Address) Sh\Smt\Km\So\Wo\Do :

8. Are you willing to accept Scheme Certificate in lieu of withdrawal benefits : (a) YES 9. Particulars of family (Spouse & Childrens & Nominee.) Name Date of Birth Relationship with Member (a) Family Members

(b) NO Name of the guardan of Minor

(b) Nominee. 10. In case of death of the member after attaining the age of 58 years without filling the claim : (a) Date of death of the Member : (b) Name of the Claimant(s) / and relationship with the Members : 11. MODE FOR REMITTANCE [ PUT A TIC IN THE BOX AGAINST ONE OPTED ] (a) By postal money order at my cost to address given against item No.7 (b) Account payee cheque sent direct for credit to my SB A/C (Sheduled Bank) under intimatin to me. S.B. Account No Name of the Bank (in block letters) Branch (in block letters) Full address of the Branch (in block letters) 12. Are your availing pension under EPS - 95 ? If so indicate : P P O NO : By Whom Issued : X

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE.

X
Date: ______ /_____ /20____. Signature of Left/Right hand thumb impression of the Member 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 towards the settlement of my Pension Fund Accounts. (The Space should be left blank which shall be filled by Regional Provident Fund Commissioner /Officer-in-Charge)

Affix 1/= Rupee Revenue Stamp.

Signature of Left/Right hand thumb impression of the Member Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me. The details of wages and 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 employees Provident Fund Office)Wages (Basic + D.A) as on 15.11.95(if applicable)Wages as on the FOR SPARSH BPO SERVICES LTD. Period of non contributory Service Year/Month Days Date: ______ /_____ /20____. AUTHORISED SIGNATORY. Signature of Employer/ Authorised Official . SPARSH BPO SERVICES LTD. INTELENET TOWER, PLOT CST NO 1406 - A / 28, MALAD (WEST), MUMBAI : - 400 064. FOR THE USE OF COMMISSIONERS OFFICE. Under Rs : P.I.No. Passed for payment for Rs. M.O. Commission (if any) In words Net Amount to be paid by M.0 towards withdrawal benefit. M.O./Cheque

D.H

S.S (FOR USE IN CASH SECTION).

A.A.O

Paid by inclusion in cheque No No. 10 Debit item No.

Date

vide cash Book(Bank) Account.

D.H For issue if S.S;. IDS is enclosed. D.H S.S

S.S

A.C (A/Cs)

A.A.O/APFC(A/Cs)

(FOR USE IN PENSION SECTION) Scheme Certificate bearing the control No Issued on and entered in the scheme Certificate Control Register

D.H

S.S

APFC(Pension)