APPLICATION FOR MONTHLY PENSION FORM 10-D(EPS)

EMPLOYEErsquoS PENSION SCHEME 1995

(Read INSTRUCTIONS before filling in this Form) 1 By whom the pension is Claimed 2 Type of Pension Claimed 3 (a) Memberrsquo Name

(In Block Letters) (b) Sex (c) Marital Status (d) Date of BirthAge (e) ParentSpouse Name

4 EPF Account Number RO SRO Establishment Code No Membersrsquos Accounts No 5 Name amp Address of the establishment in which the member was last employed 6 Date of Leaving Service 7 Reason for leaving Service 8 Address for communication PIN ______________________ 9 Option for commutation of 13 of Quantum Yes No Amount Pension (If option is for lesser) commutation indicate the quantum

Forward Office Use Only Inward No

10 Option of Return of Capital Yes No (Please refer Serial Number 10 of INSTRUCTIONS)

[Put a Tick ( )] If Yes indicate your choice of alternative 11 Mention your Nominee for Return of Capital Name Relationship Date of Birth Address 12 Particulars of Family SI No Name Date of

BirthAge Relationship

with Member

Indicate against Minor

Guardian Relationship with Member

(1) (2) (3) (4) (5) (6)

Note If any child is physically handicapped please indicate ldquoDISABLEDrdquo below the name 13 Date of death of Member (if applicable) 14 Details of Saving Bank Account Opened (1) Name of the Bank (2) Name of the Branch (3) Full Post all Address PIN CODE

3 2 1

SINo Name of the Claimants(S) Saving Bank Accounts No

14(A) If the claim is preferred by nominee indicate hisher (1) Name (2) Relationship with the deceased Member 15 Details of Scheme Certificate Scheme Certificate received amp enclosed Already in possession of the Not Received Member if any Not Applicable If received indicate SI No

Scheme Certificate Control No Authority who issued the Scheme certificate

16 If Pension is being drawn PPO No

Under EPS 1995 issued by

17 Documents enclosed (Indicate as per the Instructions) 1 2 3 4 5 6 7 8 9 10

RO SRO

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

(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 - (In case the wages is not earned for all 12 months the block of 12 months will commence backwards from the last drawn)

Year Month Wages Pension Details of period of non-contributory service If there is

no such period indicate lsquoNilrsquo No of

Days Amount Year Noof days for which no

wages were earned (1) (2) (3) (4) (5) (6) (7)

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 amp Date

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

10 Option of Return of Capital Yes No (Please refer Serial Number 10 of INSTRUCTIONS)

[Put a Tick ( )] If Yes indicate your choice of alternative 11 Mention your Nominee for Return of Capital Name Relationship Date of Birth Address 12 Particulars of Family SI No Name Date of

BirthAge Relationship

with Member

Indicate against Minor

Guardian Relationship with Member

(1) (2) (3) (4) (5) (6)

Note If any child is physically handicapped please indicate ldquoDISABLEDrdquo below the name 13 Date of death of Member (if applicable) 14 Details of Saving Bank Account Opened (1) Name of the Bank (2) Name of the Branch (3) Full Post all Address PIN CODE

3 2 1

SINo Name of the Claimants(S) Saving Bank Accounts No

14(A) If the claim is preferred by nominee indicate hisher (1) Name (2) Relationship with the deceased Member 15 Details of Scheme Certificate Scheme Certificate received amp enclosed Already in possession of the Not Received Member if any Not Applicable If received indicate SI No

Scheme Certificate Control No Authority who issued the Scheme certificate

16 If Pension is being drawn PPO No

Under EPS 1995 issued by

17 Documents enclosed (Indicate as per the Instructions) 1 2 3 4 5 6 7 8 9 10

RO SRO

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

(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 - (In case the wages is not earned for all 12 months the block of 12 months will commence backwards from the last drawn)

Year Month Wages Pension Details of period of non-contributory service If there is

no such period indicate lsquoNilrsquo No of

Days Amount Year Noof days for which no

wages were earned (1) (2) (3) (4) (5) (6) (7)

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 amp Date

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

SINo Name of the Claimants(S) Saving Bank Accounts No

14(A) If the claim is preferred by nominee indicate hisher (1) Name (2) Relationship with the deceased Member 15 Details of Scheme Certificate Scheme Certificate received amp enclosed Already in possession of the Not Received Member if any Not Applicable If received indicate SI No

Scheme Certificate Control No Authority who issued the Scheme certificate

16 If Pension is being drawn PPO No

Under EPS 1995 issued by

17 Documents enclosed (Indicate as per the Instructions) 1 2 3 4 5 6 7 8 9 10

RO SRO

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

(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 - (In case the wages is not earned for all 12 months the block of 12 months will commence backwards from the last drawn)

Year Month Wages Pension Details of period of non-contributory service If there is

no such period indicate lsquoNilrsquo No of

Days Amount Year Noof days for which no

wages were earned (1) (2) (3) (4) (5) (6) (7)

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 amp Date

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

16 If Pension is being drawn PPO No

Under EPS 1995 issued by

17 Documents enclosed (Indicate as per the Instructions) 1 2 3 4 5 6 7 8 9 10

RO SRO

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

(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 - (In case the wages is not earned for all 12 months the block of 12 months will commence backwards from the last drawn)

Year Month Wages Pension Details of period of non-contributory service If there is

no such period indicate lsquoNilrsquo No of

Days Amount Year Noof days for which no

wages were earned (1) (2) (3) (4) (5) (6) (7)

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 amp Date

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

(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 - (In case the wages is not earned for all 12 months the block of 12 months will commence backwards from the last drawn)

Year Month Wages Pension Details of period of non-contributory service If there is

no such period indicate lsquoNilrsquo No of

Days Amount Year Noof days for which no

wages were earned (1) (2) (3) (4) (5) (6) (7)

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 amp Date

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

(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 - (In case the wages is not earned for all 12 months the block of 12 months will commence backwards from the last drawn)

Year Month Wages Pension Details of period of non-contributory service If there is

no such period indicate lsquoNilrsquo No of

Days Amount Year Noof days for which no

wages were earned (1) (2) (3) (4) (5) (6) (7)

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 amp Date

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

(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 9Form 3(PS) Master Ledger CardClaim Inward Register Form 2(R) enclosed along with the documents furnished by the claimant CLERK SS AAO APFC 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 PPO may be generated through Computer CLERK SS AAO APFC(Pension) date date date date

FOR USE IN PENSION DISBURSEMENT SECTION PPO No Date of issue to the Bank Intimation sent to the Claimant and also to Accounts Branch on CLERK SS AAO APFC date date date date

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

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

Descriptive of Pensioner and hisher Specimen SignatureThumb impression 1 Name of the Member

2 EPF Account Number

3 Name of the Pensioner

4 FatherHusband name

5 Sex

6 Nationality

7 Religion

8 Height

9 Personal Marks of 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Identification 2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

10 Speciment signature of Pensioner 1helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

3helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME 1976

Regn No

FORM 5(IF)

(Form to be used by a nomineelegal heir of the deceased or guardian of the minor nominee(s) legal heir under paragraph 23 of this Scheme Note Read the ldquoInstructionsrdquo carefully before completing this form)

(Through the Employer under whom the deceased was last employed) I Being a nomineeLegal heirguardian or minor nominee(s) or minor heir of the deceased employee apply for the payment of Assurance Benefit under Employeersquos Deposit Linked Insurance Scheme 1976

(FOR USE BY THE NOMINEELEGAL HEIR OTHER THAN MINORS)

Name amp Address of the Applicant

Sex Age or year of Birth

Marital Status

Relationship with the deceased

Remarks

(1) (2) (3) (4) (5) (6)

(FOR USE IN RESPECT OF MINOR NOMINEE(S) HEIR(S))

Name amp Address of

the Applicant

Sex Age or year of Birth

Name of minor nominee

Sex Age or year of Birth

Relationship of the

guardian with the minor

nominee heir(s)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8)

2 The particulars in respect of the deceased member are furnished below- a Name of the deceased____________________________________________________________________ b Fatherrsquos Name (or husbandrsquos name in the case of married woman)_________________________________ c Date of death___________________________________________________________________________ d Last employed in ________________________________________________________________________ e Account Number in Provident FundInsurance Fund_____________________________________________ 3 The particulars of the Saving Bank Account into which the amount is to be deposited (Paragraph 24 (3) of the Employees Deposit Linked Insurance Scheme (1976) ) a Name and address of the claimant b Name and full address of the Bank specified in the first Schedule to the Banking Companies (Acquisition and transfer of the undertakings Act 1970 ) c Savings Bank Account Number of the claimant 4 I declare that the above particulars are true to the best of my knowledge Date Signature or leftright hand thumb impression of ShriSmt Kum(The Applicant )(Left thumb impression in the case of illiterate male applicant and right thumb impression in the case of illiterate female applicants)

ADVANCE STAMPED RECEIPT Received a sum of Rs helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip(Rupees) helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip) from the Regional Provident Fund CommissionerOfficer incharge of Sub-Regional officehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipby deposit in my savings Bank Account towards the Employees Deposit Linked Insurance benefit Date The space should be left blank which shall be filled in by Regional Provident Fund CommissionerOffice in Signature or leftright hand thumb charge of Sub-Regional office impression of the claimant

Certified that the CLAIMANT signedthumb impressed before me Enclosure- SIGNATURE OF THE EMPLOYER OR ANY AUTHORISED OFFICIAL Designation Dated200 Stamp of the FactoryEstt

Affix Re100 Revenue Stamp

Scanned by CamScanner

Scanned by CamScanner

करमचारी भविष म िधि सगठध wwwepfindiagovin EMPLOYEESrsquo PROVIDENT FUND ORGANISATION

रत मE रार म रक कप ो जिट द वािा रपत र Composite Claim Form in Death Cases

रपत र -20 (भविष म िधि भEगताध) रपत र 10-डी ( कशध)रपत र -5आईएफ (ईडीए आई) [Form-20 (PF Payment)Form-10-D (Pension) Form - 5 IF (EDLI)]

1 (जो लाग हो उस पर निशाि लगाए)

Tick whichever isare applicable

(i) भविष a निि

Provident Fund ( )

(ii) पशि Pension ( )

पशि दािा का परकारType of Pension claim

(iii) बीमा (ईडीएलआई) Insurance EDLI] ( )

2 मतक सदस a का िाम (बड शब दो म) Name of the deceased member (in CAPITAL letters)

3 (a) वपता का िाम Fatherrsquos Name a)

(b) पनतपत िी का िाम Spousersquos Name b)

4 मतक सदस a क िविािहक सतनत Marital status of deceased member

5

a) मतक सदस a का आ ार िबर (aिद उपलब हो) Aadhar Number of the deceased member (if available)

b) aएएि Universal Account Number (UAN)

c) भविष a निि खाता सख aा (aिद aएएि उपलब िह हव) PF Account

Number (in case UAN not available)

6 सिा छोडि क नतित Date of Leaving service

7

a)Whether Scheme Certificate has been issued (YesNo) क aा सक म परमाणपतर जार ककaा गaा हव (हािह )

b)If Yes Number of Scheme Certificate aिद हा सक म परमाणपतर क सखaा

c)Scheme Certificate issuing office सक म परमाणपतर जार करि िाल काaाालa का िाम ि पता

8 गवर अशदाaी सिा क अिि (िरामाहिदि) Period of Non-Contributory

service (YearMonthDays) ndash (To be filled by the employer)

9 सदस a क मत aव क नतित Date of death of the member

10 क aा सदस a क मत aव सिाकाल क दाराि हवई ती (हािह ) Whether the member had died while in service(Yes No)

भविष म िधि कशध तथा बीरा (ईडीए आई) हमतE वािाकताम का वििरण CLAIMANTrsquoS DETAILS FOR PROVIDENT FUND PENSION AND INSURANCE (EDLI)

11

दािाकताा अव aस क िाममनत काििी उततराि कार ितामाि पररिार क सदस a का वििरण जिक दिारा दािा परस तवत ककaा गaा हव Particulars of the claimantminornominee(s)legal heir(s)surviving family member on whose behalf the claim is submitted

करस SN

िाम Name

वपताFatherrsquos

पनत-पत िी का िाम

Spousersquos Name

आ ार िबर

Aadhar Number

मलग Gender

जन म नतित Date of Birth

िविािहक सतनत

Marital Status

सब Relationship with

सदस a क सात

Member

अमभभािक Guardian

i

ii

iii

iv

v

In case of more than five family members the details of family members may be furnished in a separate sheet duly attested by the employer

12

भविष म िधि तथा ईडीए आई (बीरा) कम भEगताध हमतE बक खातम का वििरण Bank Account details for payment of PF amp EDLI

भवगताि हतव बक खात का वििरण Bank Account details for payment

Claimant ndash I

दािाकताा ndash I Claimant ndashII

दािाकताा ndash II

Claimant ndashIII

दािाकताा ndash III

Claimant ndash IV

दािाकताा - IV

िाम Name

बचत बक खाता सख aा

Saving Bank Account No

बक का िाम ि पता Name amp address of the Bank

आई एफ एस कोड

IFS Code of Bank

कशध हमतE बक खाता वििरण BANK ACCOUNT DETAILS FOR PENSION

13

भवगताि हतव बक खात का वििरण Bank Account details for payment

Claimant ndash I

दािाकताा ndash I Claimant ndashII

दािाकताा ndash II

Claimant ndashIII

दािाकताा ndash III

Claimant ndash IV

दािाकताा - IV

िाम Name

बचत बक खाता सख aा

Saving Bank Account No

बक का िाम ि पता Name amp address of the Bank

आई एफ एस कोड

IFS Code of Bank

14 दािाकताा का पतर व aिहार का पता

Full Postal address of claimant वपि Pin

- aह परमाणणत ककaा जाता हव कक उपaवाक त वििरण मर जािकार क अिवसार स ह हव - Certified that the particulars are true to the best of my knowledge

दािाकताा का हस ताकषर Claimantrsquos signature निaोक ता का हस ताकषर

Employerrsquos Signature

िाम Name helliphelliphelliphelliphelliphelliphelliphellip निaोक ता का पदिाम तता मवहर Designation amp Seal of Employer

i) मत aव परमाणपतर Death Certificate

ii) सभी दािाकतााओ का सaव क त फोो ो Joint photograph of all the claimants

iii) दािा करि िाल बच चो क जन म का परमाणपतर Date of Birth certificate of children claiming pension

iv) aोजिा परमाणपतर (aिद लाग हो) Scheme Certificate (if applicable)

v) बक खात क सत aापि हतव एक रदद चवक पासबवक क पहल पज क अमभपरमाणणत परनतमलवप For verification of bank accounts a copy of cancelled cheque or attested copy of first page of bank Pass Book

wwwepfindiagovin

मोबाइल न

Mobile No

Mobile

Number

सलग िकEnclosures Enclosures