Forward Office Use Only

Inward No.

APPLICATION FOR MONTHLY PENSION

FORM 10-D(EPS)
EMPLOYEE’S PENSION SCHEME, 1995

(Read INSTRUCTIONS before filling in this Form)

1. By whom the pension is Claimed ? 2. Type of Pension Claimed.

WIDOW AND CHILDREN WIDOW PENSION

3. (a) Member’ Name (In Block Letters) : RAGHUVEER CHAND

(b) Sex : MALE

(c) Marital Status : MARRIED
(d) Date of Birth/Age : 20-09-1980
(e) Parent/Spouse Name : JAMAN CHAND

4. E.P.F. Account Number RO SRO Establishment Code No.

: E DL 4070

Members’s Accounts No:

5. Name & Address of the establishment : NTPC LTD., SCOPE COMPLEX, LODHI ROAD
in which the member was last employed NEW DELHI

6. Date of Leaving Service : 20-04-2017-DEATH

7. Reason for leaving Service : DEATH
8. Address for communication :

CHAND COTTAGE, DURGA VIHAR-PHASE I, KUSUMKHERA, KAADUNGHI ROAD

HALDWANI

PIN: 263139

9. Option for commutation of 1/3 of Quantum: Yes No Amount

Pension (If option is for lesser) commutation indicate the quantum NA

10. (Please refer Serial Number 10 of INSTRUCTIONS) [Tick ( )] Yes 1No

If Yes, indicate your choice of alternative 1 2 3

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11. Mention your Nominee for Return of Capital :

Name : N.A.
Relationship :
Date of Birth :
Address :

12. Particulars of Family

Relationship Indicate against Minor

SI. Date of
Name with Relationship
No. Birth/Age Guardian
Member with Member
(1) (2) (3) (4) (5) (6)
1 SANGEETA CHAND ####### WIFE
2 JYOSHIKHA CHAND ####### DAUGHTER
3 BHUMIKA CHAND ####### DAUGHTER

Note : If any child is physically handicapped, please indicate “DISABLED” below the name.

13. Date of death of Member (if applicable) : N.A.

14. Details of Saving Bank Account Opened :

(1) Name of the Bank : STATE BANK OF INDIA

(2) Name of the Branch : KUSUMKHERA
(3) Full Postal Address : KALADHUNGI ROAD, HALDWANI
PIN CODE : 263139

SI.No Name of the Claimants(S) Saving Bank Accounts No.

1 SANGEETA CHAND 20271379689
2 JYOSHIKHA CHAND 36931696398
3 BHUMIKA CHAND 43126362867

14(A) If the claim is preferred by nominee, indicate his/her

(1) Name :
(2) Relationship with the deceased Member : N.A.

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15. Details of Scheme Certificate Scheme Certificate
N.A.
received & enclosed

Already in possession of the Not Received N.A.

Member, if any Not Applicable

If received, indicate:

SI. No Scheme Certificate Control No. Authority who issued the Scheme certificate

N.A

16. If Pension is being drawn Under E.P.S., 1995 PPO No. RO SRO
issued by N.A

17. Documents enclosed (Indicate as per the Instructions)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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 TO BE SUBMITTED IN DUPLICATE IN RESPECT OF
EACH PERSON ELIGIBLE FOR PENSION

Descriptive of Pensioner and

his/her Specimen Signature/Thumb impression

1. Name of the Member : RAGHUVEER CHAND

2. E.P.F. Account Number : E/DL/4070/
3. Name of the Pensioner : JYOSHIKHA CHAND
4. Father/Husband name : RAGHUVEER CHAND
5. Sex : FEMALE
6. Nationality : INDIAN
7. Religion : HINDU
8. Height : 157 CMS
9. Personal Marks of Identification : 1 BLACK MOLE ON LEFT UPPER LIP
: 2

10. Speciment signature of Pensioner : 1

: 2

: 3

10. (Only in the case of illiterate Claimant (Pensioner)

Left Hand Finger Impression);

THUMB INDEX MIDDLE RING SMALL

Signature

Name of attesting Authority

Official Seal:
Place :
Date :

Certified that:

(i) I am not drawing Pension under Employees Pension Scheme, 1995

(ii) The particulars given in this application are true and correct.

Signature of the applicant /

Left hand Thumb Impression

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 (TO BE FILLED IN BY THE EMPLOYER /
AUTHORISED OFFICER OF THE ESTABLISHMENT)

Certified that:

(i) the particulars of the member are correct;

(ii) the particulars of Wages and Pension Contribution for the period of 12 months preceeding the date of leaving service are as under :-

Details of period of noncontributory service. If

Wages
there is no such period, indicate ‘Nil’
Year Month Pension
No.of days for which no wages were
Year
earned

Encls: 1. Documents as given in the Instructions.

2. Form of descriptive roll and specimen signature.

Signature of Employer/
Authorised Official of
The Establishment with
Seal & Date

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 (FOR OFFICE USE ONLY)
(PENSION SECTION / ACCOUNTS SECTION)

Certified that the particulars in the application have been verified with the relevant concerned documents. The claimant is
eligible for Pension. The Input Data Sheet is placed below for approval.

Entered in Form 9/Form 3(PS), Master Ledger Card/Claim Inward Register

Form 2(R) enclosed along with the documents furnished by the claimant.

CLERK S.S A.A.O A.P.F.C

date date date date

FOR USE IN PENSION PRE-AUDIT CELL

The Input data sheet verified with reference to the application and the documents enclosed and found correct. P.P.O. may be
generated through Computer.

CLERK S.S A.A.O A.P.F.C

date date date date

FOR USE IN PENSION DISBURSEMENT SECTION

P.P.O. No :

Date of issue to the Bank :

Intimation sent to the Claimant and also to Accounts Branch on :

CLERK S.S A.A.O A.P.F.C

date date date date

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