Mr./Ms.

____________________________________ You have either of the following options regarding settlement of your Provident Fund dues: 1) Withdrawal: You may withdraw your P.F. accumulations if you have not joined another organisation in India or joined an organisation, which is not covered under PF rules. On receiving a declaration from you stating that your current/future organisation is not covered under the P.F. Rule or you are/will not be employed anywhere in India, you may withdraw your P.F. Accumulations to your credit. The P.F.amount due will be paid to you after deducting necessary taxes, if any. However, if your total P.F membership is greater than 5 years then no tax will be deducted on withdrawal of your P.F. Dues. Please note settlement of your P.F. Dues will be done, if you do not have any other dues with the bank. Incase of withdrawal employee need to fill below attached detail 2) Transfer of PF accumulations: If your current/future employer is covered by P.F. Rules, you have to transfer the P.F. Accumulations to the P.F. Account of your employer. You are requested to fill in the Form13 in duplicate with your new employer and forward the duly filled and signed form through your new employer . Transfer will be effected on receiving Form 13 from your employer. (Note Your PF account number is your Employee Code followed by X and the funds are administered by HDFC Bank Ltd. Covered Employees PF Trust.) No tax will be deducted on transfer of P.F. Accumulations to another organisation covered under P.F. Rule. We request you to give your option to The Trustees of HDFC Bank Employees Provident Fund Trust, PAD- Finance , Lodha - I Think Techno Campus, Building - Alpha, 8th Floor, Next to Kanjur Marg Railway Station (East), Kanjur Marg (E), Mumbai 400 042 in writing regarding settlement of P.F. dues. Employees confirmation on PF settlement: - ( Please Tick Option below) I wish to confirm option no. 1 [ ] (Withdrawal) [ ] 2 (Transfer to New Employer In case of withdrawal, I confirm that I have not joined any organisation in India or joined an organisation, which is not covered under PF rules. Signature of Employee ____________________ Name of Employee : _______________________ Date : ___________________ Employee Code : __________

P.F. will be credited to your HDFC Salary A/C Only if your salary A/c is closed then it can be credited to any other A/c HDFC Bank Salary A/c no. : _____________________________ Complete Correspondence Postal Add. _________________________________________ __________________________________________ __________________________________________

Contact no(R) Email : _________________________.

(M)

PLEASE ATTACH A CANCELLED CHEQUE ALONGWITH THE FORM. OTHERWISE THE P.F. OFFICE DOES NOT ACCEPT THE FORM
Form 10 C Guidelines to fill the Form 10C.

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 Form10C is not be submitted to us you have to fill in the Form 13 in duplicate with your new organization.
1)
B)

Name
Name of the Claimant :

: : :

Your Full Name is Block Letter

Your Full Name is Block Letter

2) 3) B)

Date Of Birth Father Name Husbands Name

Birth date is DD / MM / YYYY format : Father Name For Female Candidates if Joined the Organisation before marriage then please attached the Marriage Keep it blank will be updated by us Keep it blank will be updated by us : Resigned Your Last working day in the organization

Certificate. 4) Name & Address of the Estb: 5) Code No & Account No : 6) B) 8 Reason for Leaving Service Date of Leaving :

Your complete postal address Your complete postal address with mobile number
Are you willing to accept Scheme Certificate in lieu of withdrawal benefit Yes / No

(Note if you wish to take the benefit of the Scheme after your retirement age then please opt for option 1 ( Yes ) in that case RPFC will issue you a certificate which has to be surrendered to RPFC on retirement.( Please enclose the birth certificate of your family member along with the form 10c if your option is for scheme certificate & do not sign the Advance Stamp receipt on the last page. / But if you wish to withdraw the money in full then you have to opt for second option.)
9 Particulars of Family ( Spouse , Children & Nominees : Please mention the details of your family ( Family means Wife & Children . 10 This column is applicable for The deceased members only 11) Mode of Remittance Your Bank Details Account Number with complete address Are you availing pension under EPS 95 : Yes / No ( Please disclose if you are getting any pension from any of your Previous organization.)

12)

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. (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 90 days.)

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) 3) a) b)

Date of Birth

________/___________/_______________

Fathers Name : ________________________________________________________________ Husbands Name (if applicable) : ________________________________________________________________ 4) Name & Address of the Establishment HDFC BANK LTD., In which, the member was last employed. PAD - FINANCE, LODHA - I THINK TECHNO CAMPUS BUILDING - ALPHA, 8TH FLOOR, NEXT TO KANJUR MARG RAILWAY STATION (EAST), KANJUR MARG (E), MUMBAI 400042

5) 6)

Code No. & Account No. Reason for leaving service & Date of leaving

: : :

MH / 46135 / RESIGNED _____/_________/___________

7)

Address

_______________________________________________________________

________________________________________________________________ Tel : Number E-Mail ID ___________________________ Moblie No. __________________________ __________________________________

8) Are You willing to accept Scheme Certificate in lieu of withdrawal benefit : Yes 9) Particular of Family (Spouse, Children & Nominees) Family Member Name Date of Birth

No Name of the guardian of minor

Relationship With Member

10)

Incase of death of member after : attaining the age of 58yrs without filling the claims (a) Date of death of member : ________________________________________________________________ : ______________________________________________________________

(b) Name of the Claiment(s) and Relationship with the member

11) MODE OF REMITTANCE (PUT A RICJ 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 SB A/c (Scheduled Bank) under intimation to me. S.B. Account No. Name of the Bank (In Block letter Branch Name (in Block Letter) Full Addresses of the Branch (In Block Letters) 12) : : : : ______________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

_________________________________________________________________ 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 / Claiment __________________________________________________________________________________________________________________ 13) ADVANCE STAMP RECEIPT ( TO BE FURNISHED ONLY IN CSE 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 (FOR USE IN CASH SECTION)

A.A.O

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 S.S A.A.O (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) APFC (A/cs)

C.C