Steps for filling Pension Withdrawal form • Mention your Employee Code 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.3 • Point no 4,5,6 leave it blank • Point No.9, 10, & 12 – Please leave it blank Point n o.11 please mention the complete Bank branch address • It is Mandatory to attach “ORIGINAL CANCELLED CHEQUE “ along with the Pension withdrawal form pe rtaining to any of the saving Bank account numb er mentioned on point no 11 or else the form will get rejected by the Regional Provident Fund Commissioner . • Signature on bottom of the Page 2 where (X) is marked . Fix revenue stamp & signed across on Page 3 & keep all the details blank • Page 4 please keep it blank • Address for sending the pension withdrawal form: o ICICI Prudential Life Insurance Company Ltd, o Shared Services - HR Ops ( PF Team) o Grd Floor, Vinod Silk Mills Compound, Ashok Nagar, o Chakravarti Ashok Road, Kandivali - East, Mumbai - 400 101
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• Mention your Employee Code 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.3
• Point no 4,5,6 leave it blank
• Point No.9, 10, & 12 – Please leave it blank
Point no.11 please mention the complete Bank branch address
• It is Mandatory to attach “ORIGINAL CANCELLED CHEQUE “along with the
Pension withdrawal form pertaining to any of the saving Bank account numbermentioned on point no 11 or else the form will get rejected by the Regional ProvidentFund Commissioner .
• Signature on bottom of the Page 2 where (X) is marked . Fix revenue stamp & signed
across on Page 3 & keep all the details blank
•
Page 4 please keep it blank
• Address for sending the pension withdrawal form:
o ICICI Prudential Life Insurance Company Ltd,
o Shared Services - HR Ops ( PF Team)
o Grd Floor, Vinod Silk Mills Compound, Ashok Nagar,
8. Are you willing to accept SchemeCertificate in lien of withdrawal benefit Yes No
9. Particulars of Family (Spouse, Children’s & Nominees)
NameDate OfBirth
Relationship withMember
Name of the Guardian ofminor
(a) Family
Member
(b) Nominee
10. In case of death of member after attaining the age of 58 years without filling theclaim:
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 meS.B Account No. ____________________________________(Mandatory to attach a cancelledcheque along with the form)Name of the Bank ____________________________________
(In Block Letters) ____________________________________
Branch ____________________________________
(In Block Letters) _____________________________________
Full Address of the Branch _____________________________________(In Block Letters) _____________________________________
12. Are you availing pension under EPS-95?If so indicate : PPO No._________________ By Whom Issue______________________________________________________________________________________
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE
Date: _________________ Signature or Left Hand
____________________________ (X) Thumb impression of theMember / Claimant
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 FundCommissioner / Officer – in – charge)
(X) Signature or Left hand thumb impression ofthe member on the stamp
Certified that the particulars of the members given are given are correct and themember has signed / thumb impressed before me.
The details of wages and the period of non-contributory services of the memberare as under:-(Form 3A/7 (EPS) enclosed for the period for which it was not sent to theemployee’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 services Year / Month _______________________ days ______________________