To,

The Trustees,
ShapooriiPallonJl & Co. Ltd. Employees'Provident Fund'
SP Centre, 41 144, Minoo Desai Marg,
Colaba, Mumbai 400005.
Date ol Application:
Dear Sir (s),
I hereby request ycu to pay the amount $anding to my credit in the fund after making such deductions as may be authorized
under the kovident F.rnd Trust fuledlncome Tax Act 1961 . My particulars are as below:
I certify that the pillidlars given above are lrue to the best ol my knowldge'
the nea tuture.
I hereby agre md undertake to kep you harmless md lully indemnilied lrom ad againd all losses, @st or dmages, which you may sufter or inaJr due to my withdrawal of provident tund
amount-hJving being proved to be based on a lal* dedaration at ily tinle in future'
self-rti{ied true mpy ol dooment(s) in support of my appliation iEare furnistled /endosed.
[ ft'ror to
io'ilnms
SPCLwere you a Provident Fund Member of :
1 . The Ernpioyeei' ftovident fund & Miscellaneous frovision Act , 1952 : Please specify :
ffiffiffiffiw
2. ft.ovident Fund Recognized under lncome Tax Act 1922 (1 1 of 1922) : Please specify :
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3. A1y other frovidcnt Fund Act :
Hease Speci{y :
wrffiffiwffiw,{ffi,
Name ot Fl'ovident Fund
WWWWffi
B. llad you applieci for transier of frovident fund vide form No' 13 (Rev) at the time of
loining
SPCL :
Signature of EmPloYee :
_"._-_--
Name of the Member (lN BLOCI(LETTEFS :
Father'd Husband's Name
(
I N BLm( LETTEFS)
Payroll Region
P.F. Account No.: MH/ BAN/ 198441X|
P.AN. No.
Date of Erth : f* I Me4 I YYYY Date of
joining kovident tund : ** i ffiM r YYYY
Date of leaving service : *tr} i *&f8 I YVY"{
Fbasons lor leaving service :
Oomplete Residential fustal address with PIN Oode
(IN
BLOC}< LETTEFS)
(Also enclose self.cerlitied true copy of residential address Proof
f or communication & Dispatch of Cheqqe
| --'---
Personal E-mail-id:
Telephone with SID code :
ffithe
date of
joining to date of
leaving issued by
SPCL,
in case the employee is having
membership for less than 5
Years.
Enclosed lor the vears:
i. iii. v.
ll. iv.
ADVANCE STAMPED RECEI PT
Beceived from $rapoorii Pallonii & Oo. Ltd. Bnployees' Bovident fund the sim of
(
/- ( fupees
--
Being the f ull payment of ftovident fund Accumulations to the credit of my ftovident fund Account with them'
(
Name & Signature of Claimant)
3 of 3
1211412012 5:
;fror
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Serial No:
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In Words No.
Form No.10 C (E.P.S)
EMPLOYEES' PENSION SCHEME, 1995
F1RM To BE usED BY A MEMBER oF THE EMPLIYEEI'pEtts,oN sc HEMET
1 995 FO R CLAIMING VlITHDRAWAL BEN EFIT\SCHEME CERTIFICATE
(Read
tlre instructions before fillinq up this forml
2.
a) Name of the member :-
( ln Block Letters)
b) Narne of the claimant (s)
Date Of Birth
a1 Father's Name
l,--n T-T-t TT__l
b) Huslandls Nam-e
(lf applicable)
4. Name & Address of the Establishment
in rvhich, the member lvas last employed
Code No. & Account No.
Reason for leaving service
& Date of leaving
Full Postal Address :-
(ln Block Letlers)
MOBILENO.:
SHAPOORJI PALLONJI & CO. LTD.
ADMINISTMTIVE OFFICE
SP CENTRE,4Il44 M1NOO DESAI MARC,
COLABA, MUMBAI 4OOOO5.
MIIIBAN/19844DV
RISIGNED
6.
7.
PIN
- l':or lSvaluabon Only.
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8" Are you willing to accept Scheme (a) (b)
N"E
Certificate in lieu of withdrawal benefits Yes
fl
9. Particulars of Family (Spouse & Chidren & Nominee)
Name
,r}fflfJf,
Retationship with Member
Name of the
suardan
of minor
(a)
(b)
(c)
(d)
Nominee
10. ln case of death of member after attaining the age of 58 years without filing the claim:-
(a) Date of death of the member :
(b) Name of the Claimant(s) / and relationship vyith the members :
11. MODE FOR REMITTANCE
IPUT
A TICK tN THE BOX AGAINST THE 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 fuc (Scheduled Bank) under intimation
LI
S.B. Accounts No.
Name of the Bank
(in block letters)
Branch
(in block letters)
Full Address Of the Branch
(in block letters)
PIN CODENO.:
12. Are your availing pension under EPS-95 ?
lf so indicate : PPO NO. By Whom lssued
Certified THAT TtlE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date
Signature or lefl Hand
Thumb lmpression of the
Member / claimant(s)
ADVANCE
STAMPED
RECEIPT
[To
be furnished only in case of (b) above]
Received a sum of Rs................(Rupees.....
.......................)
only from Regional Frovident 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 lefi blank which shall be filled by Regional
provident
Fund commissioner
/offlcer-in-
charge)
Signature & left hand thumb impression of the member on the stamp
certified that the particulars
of the member given
are correct and the member has signed/thumb impressed
before me.
Thedetailsof'wages
andpcriot oT nbn-eonlaiFutory
serviae oiihe member are asunder:-
Form 3Ar/ (EPS) enclosed for the period
for which it was not sent io employee's
provident
Fund office)
Wages (Basic + D.A) as on 15.11.95(if appticable)
Wages as on the date of exit
P-eriocl
of non contributorv Sorvice
Year/Month
No.of days-
Date
Signature of Employer/
authorised Official
(FOR THE LJSE OF COMMTSSIONER'S OFFTCE)
(Under Rs
M.O. Commission (if any)..........,. ...net amount to be paid by M.O
tovrards vrithdrawal benefi t.
D.H. S.S A.A.O
(FOR USE tN CASH SECilON)
No. 10 Debititem No........
S.S AC(A/cs) D.H
For issue if S.S:. IDS is enclosed.
D.H S.S A.A.o/APFC(A/cs)
(FOR USE tN PENSTON SECTTON)
Scheme Certificate bearing the control No........,.............:......................Issued on.............................and
entered in the scheme Certificate Control Register-
D.H S.S 'A.A.O
APFC(PENSION)
.:
.
DOCU MENTS REQUINE TbN WiTHDRAVfAL bF P;F AI'IOUNT
t aPPoINMENT TETTER (CANDTDAIE)
'
2 REsrcNrrrrrnlcal.iOronrrl
3 RESIGN A@?Tt\r.rCE
I,ETTER
(r{R)
4 P/iNCARD(CANDIDATE)
.
s roRr{ 16 (E\ERyYEAR) (CANDIDATE A@rrNr)
6
(II,ARANCE
CERIFICATE(CAT.TDIDATE)
7
qTEQUE
(CAI.{GLXCANDTDATE)
8 PASS B OOK B'ANi((CAI.{DIDATE)
9 CO\IERING I-ETTER(CAI.{DIDATE)
10 DATE OF BIRII{(CAI.{DIDATE)