Guidelines to fill the Form 10C:-

I. Guidelines
II. Filled Specimen 10C Form
III. Blank 10C Form

Very important message: This form has to be filled by all the members only if they wish to withdraw their
Provident Fund Accumulation from HDFC Bank Ltd. Covered Employees PF Trust. If you wish to Transfer the
PF to your new organization then no need to submit Form10C, In that case you have to fill in the Form 13 in
duplicate with your new organization.

Employee who complete minimum 6 months of Service then only eligible for withdrawal of EPS amt.

Please read the guidelines completely and go through the Specimen Form, if any of the details are found
missing or incomplete your Form 10C will be subject to rejection.

I - GUIDELINES

1) Name : Your Full Name is Block Letter

B) Name of the Claimant : Your Full Name is Block Letter

2) Date Of Birth : Birth date is DD / MM / YYYY format

3) Father Name : Father Name

B) Husbands Name : For Female Candidates if Joined the Organisation before
marriage then please attached the Marriage Certificate.
.
4) Name & Address of the Estb : It is updated in Form

5) Code No & Account No : Keep it blank will be updated by us.

6) Reason for Leaving Service : Resigned

B)
Date of Leaving : Your Last working day in the organization

7) Your complete postal address : Your complete postal address with mobile number and email id.

8) Are you willing to accept Scheme Certificate in

lieu of withdrawal benefit Yes / No

Note :-
Opting No :- employees tenure of service is less than 10 years, then EPS amount can be withdraw
Opting Yes: - employees tenure of service is more than 10 years ,then only employee can avail Scheme
Certificate. In that case employee need to enclose the birth certificate of family member along with the
10c form & do not sign the Advance Stamp receipt on the last page, RPFC will issue you a certificate
which has to be surrendered to RPFC on retirement.
9) Particulars of Family ( Spouse , Children & Nominees : Please mention the details of your family

10) This column is applicable for The deceased members only

11) Mode of Remittance :- It is Mandatory , Your Bank Details Account Number with complete address

Note:-
Please provide ORIGINAL CANCELLED CHEQUE. If MICR code is not mentioned on the cheque
then please also attach Photocopy of Front Page of Bank Pass Book OR Latest Bank Statement duly
attested by Bank Authority along with the Pension withdrawal form pertaining to the Bank account
number mentioned on point no. 11(b..
1) Joint Saving Bank Account not acceptable / account should be in single name of member,
2) The Cheque must bear MICR/RTGS/NEFT/IFSC Code or else the same would be rejected.
3) If HDFC Salary Bank account is mentioned, then request you to continue the salary account till your
claim get settled ( It take appx 6 to 8 month to settle EPS claim by RPFC) , if your account get closed
then your claim will get rejected.

12) Are you availing pension under EPS 95 : Yes / No

(Please disclose if you are getting any pension from any of your previous organization.)

After filling the above information please sign the declaration stating the above particulars are True and to the
best of my knowledge

13) Advance Stamp Receipt : If you wish to withdraw the accumulation please put a Revenue stamp & your
signature across it in the Advance Receipt this is compulsory.

Note :-
Please note Signatures are very important if your miss to sign then we will not be able to process the form
and sent to RPFC. This form is submitted to Regional PF office Bandra after remittance of the last
months contribution to RPFC and the settlement will be processed and credited to your bank a/c by
RPFC within a Time limit of 6 to 8 month.)
 II - FILLED SPECIMEN 10C FORM

Emp. Code :- R5571

FORM 10 C (EPS)

EMPLOYEES PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWL BENEFIT /SCHEME CERTIFICATE
(Read the instructions before filling up this form)

1) a) Name of the member :- (In Block Letters) : Rajneesh Singh Kushwaha

b) Name of the Claimant : Rajneesh Singh Kushwaha

2) Date of Birth : 01 March 1982

3) a) Fathers Name : Rajesh Singh Kushwaha

b) Husbands Name (if applicable) :

4) Name & Address of the Establishment HDFC BANK LTD.,

PAD - FINANCE,
LODHA - I THINK TECHNO CAMPUS
BUILDING - ALPHA, 8TH FLOOR,
NEXT TO KANJUR MARG RAILWAY STATION (EAST),
KANJUR MARG (E), MUMBAI 400042

In which, the member was last employed. :

5) Code No. & Account No. : MH / 46135 / 5417

6) Reason for leaving service : Resigned

& Date of leaving : 01 / 03/ 2014

7) Address : 403 Raj Ganga Bldg, New Ayre Road

Kalyan , Thane 421 201

Tel : Number ______________ Moblie No. 9865745148

E-Mail ID Rajneesh.K@rediffmail.com

8) Are You willing to accept Scheme
Certificate in lieu of withdrawal benefit : Yes X No
( Tick Yes if employees has completed more than 10 years service)

Particular of Family (Spouse, Children & Nominees)

 Family Member Name Date of Birth Relationship With Member Name of the guardian of minor
1 Rajesh Kushwaha 01. 05.1950 Father

9) Incase of death of member after :

attaining the age of 58yrs without
filling the claims
(a) Date of death of member : ________N/A_________________________________________________

(b) Name of the Claiment(s) and

Relationship with the member : ________N/A__________________________________________________

10) MODE OF REMITTANCE (PUT A TIC IN THE BOX AGAINST THE ONE OPTED)
A) By postal money order at my cost to the address given against item no 7.
N/A

B) By account payee Cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation to me.

S.B. Account No. : 33933152042332

Name of the Bank (In Block letter : STATE BANK OF INDIA

Branch Name (in Block Letter) : GROUND FLOOR, EVERSHINE SAPPHIRE,

Full Addresses of the Branch : THANE - 421 211

(In Block Letters)
__N/A__________
11) Are your availing pension under EPS-95
If so, indicate ` : _________________________________________________________________
_________________________________________________________________________________________________________________

CERTIFIED THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

( SIGNATURE IS MANDATORY )

Date __01_/_03__/_2014___ Signature or left Hand Thumb Impression of the Member / Claiment
__________________________________________________________________________________________________________________

13) ADVANCE STAMP RECEIPT

( TO BE FURNISHED ONLY IN CASE OF (B ) ABOVE )

RECEIVES A SUM OF Rs. _________________ (Rupees _______________________________________________________only) from

Regional Provident Fund Commissioner / Officer In Charge of Sub Regional Office____________________ by deposit in my saving

Bank A/c. towards the settlement of my pension Fund Account.

(The Space Should be left blank which shall be filled by Regional Provident Fund Commissioner / Office-in-Charge)

Affix
Rupee
01
Revenue
Stamp
Signature or left Hand Thumb Impression of the Member / Claimant
 (Affix a 1 rupee Revenue Stamp and Across Signature Mandatory)

MH/46135/

(FOR THE USE OF COMMISSIONERS OFFICE)

(Under Rs. _______________________ P.I ____________________M. O/ Cheque passed payment for Rs. ________________________

(in words _________________________________________________________________ M. O ( if any)_______________________________

Net amount to be paid by M.O ______________________ towards withdrawal benefit

C.C S.S A.A.O

(FOR USE IN CASH SECTION)

Paid by inclusion in cheque No.______________ Dt.____________vide cash Book (Bank) Account No. 10 Debit item No._____________

S.S A.C (CASH)

For issue of scheme Certificate, Input Data Sheet is enclosed

C.C S.S 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.

C.C S.S A.A.O APFC (Pension)

 III - BLANK 10C FORM
Emp. Code :-

FORM 10 C (EPS)

EMPLOYEES PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995 FOR CLAIMING WITHDRAWL BENEFIT /SCHEME CERTIFICATE
(Read the instructions before filling up this form)

1) a) Name of the member :- (In Block Letters) : ________________________________________________

b) Name of the Claimant : ________________________________________________

2) Date of Birth : ____/____/______

3) a) Fathers Name : _____________________________________________

b) Husbands Name (if applicable) :

5) Name & Address of the Establishment HDFC BANK LTD.,

PAD - FINANCE,
LODHA - I THINK TECHNO CAMPUS
BUILDING - ALPHA, 8TH FLOOR,
NEXT TO KANJUR MARG RAILWAY STATION (EAST),
KANJUR MARG (E), MUMBAI 400042

In which, the member was last employed. :

5) Code No. & Account No. : MH / 46135 / ______

6) Reason for leaving service : Resigned

& Date of leaving : ____/____/______

7) Address : ________________________________________________

_____________________________________________

_________________________________________________

Tel : Number ______________ Moblie No. _____________________

E-Mail ID ______________________________________________________

12) Are You willing to accept Scheme
Certificate in lieu of withdrawal benefit : Yes X No
 Particular of Family (Spouse, Children & Nominees)

Family Member Name Date of Birth Relationship With Member Name of the guardian of minor

13) Incase of death of member after :

attaining the age of 58yrs without
filling the claims
(a) Date of death of member : ________ __________________________________________________
(c) Name of the Claiment(s) and
Relationship with the member : ________ __________________________________________________

14) MODE OF REMITTANCE (PUT A TIC IN THE BOX AGAINST THE ONE OPTED)
C) By postal money order at my cost to the address given against item no 7.
N/A

D) By account payee Cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation to me.

Saving Bank Account No. : _________________________________________________________

Name of the Bank (In Block letter : _________________________________________________________

Branch Name (in Block Letter) : _________________________________________________________

Full Addresses of the Branch : _________________________________________________________

(In Block Letters)

_________________________________________________________
15) Are your availing pension under EPS-95
If so, indicate ` : ______________________________________________________________
_________________________________________________________________________________________________________________

CERTIFIED THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Date ____/_____/_______ Signature or left Hand Thumb Impression of the Member / Claimant
__________________________________________________________________________________________________________________

13) ADVANCE STAMP RECEIPT

( TO BE FURNISHED ONLY IN CASE OF (B ) ABOVE )

RECEIVES A SUM OF Rs. _________________ (Rupees _______________________________________________________only) from

Regional Provident Fund Commissioner / Officer In Charge of Sub Regional Office____________________ by deposit in my saving

Bank A/c. towards the settlement of my pension Fund Account.

(The Space Should be left blank which shall be filled by Regional Provident Fund Commissioner / Office-in-Charge)

Afix Rupee 01
Revenue Stamp
 Signature or left Hand Thumb Impression of the Member / Claimant
MH/46135/

(FOR THE USE OF COMMISSIONERS OFFICE)

(Under Rs. _______________________ P.I ____________________M. O/ Cheque passed payment for Rs. ________________________

(in words _________________________________________________________________ M. O ( if any)_______________________________

Net amount to be paid by M.O ______________________ towards withdrawal benefit

C.C S.S A.A.O

(FOR USE IN CASH SECTION)

Paid by inclusion in cheque No.______________ Dt.____________vide cash Book (Bank) Account No. 10 Debit item No._____________

S.S A.C (CASH)

For issue of scheme Certificate, Input Data Sheet is enclosed

C.C S.S 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.

C.C S.S A.A.O APFC (Pension)