A/c. Gr. No. ____________ Employees Provident Funds Scheme, 1952 Regin. No. Form 20 (For Office use only) Employer's Tel. No. : ____________ Member's or Contact Tel. No. : ____________ Inquiry Tel. No. : Form to be used (1) by the guardian of minor/lunatic member. Or (2) by a nominee of legal heir of the deceased member. Or (3) by the guardian of the minor/lunatic nominee of heir. For claming the provident Fund accumulation of minor/deceased member. (Note : Read the instructions carefully before completing this form) PARTICULARS OF MEMBER 1. (a) Name of the member (in Block Letters) (b) Father's / Husband's Name. (c) Name & Address of the Factory/Establishment in which the member was last employed. (d) Account No. (e) Date of leaving service. (f) Reason for leaving service. (g) Date of death of the Member (in case of Deceased member) (h) Marital Status of the member on the day of death. PARTICULARS OF THE CLAIMANT 2. To be filled in by a Major Nominee / legal Heir / Member of the Family of the deceased Member. a) Name of the claimant (in Block Letters) b) Father's / Husband's Name c) Sex d) Age (as on the date of death of the member) e) Marital status (as on the date of death of Member) i.e. Unmarried, Married, Window or Widower f) Relationship with the deceased member 3. To be filled in by the Guardian / Manager of Minor / lunatic Member / Minor / Nomineess(s) of the Legal Heir deceased Family Member(s) member. a) Name of the claimant (i.e. Guardian) b) Father's / Husband's Name c) Relationship with the member / deceased member 3. A. Particulars of Minor/lunatic Nominee(s) legal heir(s) Family Member(s) on whose behalf the Provident Fund amount is claimed. Relationship S. No Name Sex Age Religio n Relationship with the deceased member With guardian 1. 2. 3. 4. Delete, if not applicable. 4. Claimants Full Postal Address (in block letters) Shri/Smt.___________________ S/o, W/o, H/o, D/o ___________________________ Pin ___________________ 5. Mode of Remittance ?put a tick in the box agaist the One opted(?) (a) by postal money order at my cost to the address given in item No. 4 above (b) S. B. Account No. ?by account payee cheque sent direct for credit to my S. B. A/c. (Scheduled Bank / Co-op. Bank / P. O.) under intimation to me Name of the Branch Full Address of the Branch (Advance stamped Receipt furnished below) Certificate : (1) to the best of my knowledge no posthumous child will be born to the deceased member. (2) I Certify that the particulars given above are true to the best of my knowledge. I certify that the minor(s) Lunatic Shri/Smt. _________________________________ is living with me and is being Supported and looked after by myself and the Provident Fund money claimed on behalf of minor/lunatic will be spent in his/her best interest and benefits. I certify that minor member has not been employed in any Factory/Establishment to which the act applies for a continuous periods of not less than 2 months immediately preceding the date of this application. Enclosures Date Signature of Left/Right/hand thumb impression of the claimant delete, If not applicable Contribution for the Current Financial year Worker's Shares Employer's Share Month Amount of wages E.P.F. E.P.F.(difference between 10% & 81/3% OR 12% & 81/3% as the case may be) PENSION FUND Contribution 8.1/3% No. of days/period of non- contributing service(if any) 1 2 3 4 5 6 April May June July Aug. Sep. Oct. Nov. Dec. Jan. Feb. March Total Advance stamped receipt (To furnished only in case of 5 (b) above) __________ Received a sum of Rs. ____________(Rupees _______________________________ _____________________________________________) from Regional Provident Fund Commissioner / Officer in Charge of sub Regional Office _________________ _____________ State. By deposit in my Saving Bank Account towards the settlement of Provident Fund account of Shri/Smt. ____________________________________________________________ The Space should be left blank which shall be filled in by RPFC / Office - in Charge of S.R.O Affix Rs.1.00 Revenue Stamp Signature or Left/Right hand thumb impression of the claimant _____________________________________________________________________ CERTIFICATE BY THE ATTESTING AUTHORITY Certified that the facts stated above are correct, Certified that the claimant Shri/Smt/Kumari. ______________________________________________________ is known to me and has signed/thumb impressed before me Signature of the employers or any authorized officer with Designation & Seal (For the use of commissioner's office) Account settled in part / Full Entered in form 21A/24/2/6A & withdrawal Register. Clerk S.S. (Under Rs. _____________________________ P.I.No. _______________M.O./Cheque
