1. 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 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 number
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

2. EMP ID:-
FORM 10 – C PENSION
Group No._____________
At _____________
Serial No. _____________
Inward No._____________
For Office Use Only
EMPLOYEE’S PENSION SCHEME, 1995
FORM TO BE USED BY A MEMBER OF THE EMPLOYEE’S PENSION SCHEME, 1995 FOR
CLAIMING WITHDRAWAL BENEFIT / SCHEME CERTIFICATE
(Read the instructions before filling up this form)
1. a) Name of the member __________________________________________
(In Block Letters) First name Surname
b) Name of the claimant _________________________________________
First name Surname
2. Date of Birth( DD-MM-YYYY) __________________________________________
3. a) Father’s Name _________________________________________
First name Surname
b) Husband’s Name _________________________________________
(Only incase of married female)
4. Name & Address of the ICICI Prudential Life Insurance Company Ltd
Factory / Establishment in ICICI Prulife Towers, 1089, Appasaheb Marathe,
Which the member was Prabhadevi, Mumbai – 400 025
last employed
5. Code No. & Account No MH / BAN / 49598 /
6. Reason for leaving service & Resigned
Date of Leaving _________________________________________
7. Full Postal Address (In Block Letters) ______________________________________
House no/Room no/Bldg no
______________________________________
Street No./Area/PO
_______________________________________
State & Pin Code Number
______________________________________

3. 8. Are you willing to accept Scheme
Certificate in lien of withdrawal benefit Yes No
X 
9. Particulars of Family (Spouse, Children’s & Nominees)
Date Of Relationship with Name of the Guardian of
Name Birth Member minor
(a) Family
Member
(b) Nominee
10. In case of death of member after attaining the age of 58 years without filling the
claim:
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 X
b) By Account Payee cheque sent direct for credit to my S.B a/c (Scheduled Bank)
Under intimation to me 
S.B Account No. ____________________________________
(Mandatory to attach a cancelled
cheque 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 the
Member / Claimant

4. 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 Fund
Commissioner / Officer – in – charge)
Re.1/-
Revenue
Stamp
(X) Signature or Left hand thumb impression of
the member on the stamp
Certified that the particulars of the members given are given are correct and the
member has signed / thumb impressed before me.
The details of wages and the period of non-contributory services of the member
are as under:-
(Form 3A/7 (EPS) enclosed for the period for which it was not sent to the
employee’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 ______________________
Date: _________________________
Signature of the Employer /
Authorised Official

5. (FOR THE USE OF COMMISSIONER’S OFFICE)
(Under Rs.______________________________________ P.I No.________________________
M. O. / Cheuqe
Passed for payment for Rs.._________ (in words) __________________________________
M. O. Commission(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 eclosed
C.C. S.S. A.A.O. A.P.F.C(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. A.P.F.C (PENSION)