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Form 5 If The Employees' Deposit-Linked Insurance Scheme, 1976

This document contains a form to claim benefits under the Employees' Deposit Linked Insurance Scheme, 1976. The form requests details of the deceased member, claimant/guardian, and mode of payment. It must be filled separately for each claimant, or by the guardian if the claimant is a minor. The employer must also certify details of the deceased's employment and provident fund balance. The form is to be submitted to the Regional Provident Fund Commissioner for processing the insurance payment.

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savideshwal
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© Attribution Non-Commercial (BY-NC)
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82 views

Form 5 If The Employees' Deposit-Linked Insurance Scheme, 1976

This document contains a form to claim benefits under the Employees' Deposit Linked Insurance Scheme, 1976. The form requests details of the deceased member, claimant/guardian, and mode of payment. It must be filled separately for each claimant, or by the guardian if the claimant is a minor. The employer must also certify details of the deceased's employment and provident fund balance. The form is to be submitted to the Regional Provident Fund Commissioner for processing the insurance payment.

Uploaded by

savideshwal
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

eksckby la-@ Mobile Number

nkok la[;k@Clam I.D ...................................


izi=&5 ch-fu
FORM 5 IF

deZpkjh fu{ksi lgc) chek ;kstuk] 1976


THE EMPLOYEES DEPOSIT- LINKED INSURANCE SCHEME, 1976

izR;sd nkosnkj }kjk vyx&vyx Hkjk tk,A ;fn nkosnkj ,d vYiOk;Ld gS rks mlds vfHkHkkod }kjk Hkjk tk,A ,d ls vf/kd vYiOk;Ld nkosnkj
gksus dh fLFkfr esa vfHkHkkod }kjk ,d izi= Hkjk tk,A To be filled up separately by each claimant. In case the claimant is minor
it should be filled up by the guardian on his/her behalf. Where there are more than one minor the guardian should
claim in one Form on their behalf.
fVIi.kh & bl izi= dks Hkjus ls igys ^vuqnskksa* dks /;kuiwoZd if<+,ANote - Read the Instructions carefully before completing this
form
1- e`rd lnL; dk fooj.k
The Particulars in respect of the deceased member
d e`rd lnL; dk uke
(a) Name of the Deceased member
[k firk dk uke ifr dk uke fookfgr efgyk ds ekeys esa
(b) Fathers Name (Husbands name in the case of married woman)
x e`R;q dh frfFk
(c) Date of Death (dd/mm/yyyy)
?k) QSDVh@LFkkiuk dk uke o irk ftlesa lnL; vfUre ckj Fkk@
(d) Name and Address of the Factory /Establishment
where the member was last employed.

M+ Hkfo; fuf/ka [kkrk la[;k


(e) Provident Fund Account No

{ks-@dk- dk-s
RO/Office Code

LFkkiuk dh dksM laEstt. Code No.

[kkrk laA/c No.

2- nkosnkj@vfHkHkkod dk fooj.k@ Details of the claimant/guardian.


d uke@Name
[k tUe frfFk@ Date of Birth (dd/mm/yyyy)
x e`rd ds lkFk lEca/k@ Relation with the deceased
;fn nkosnkj vfHkHkkod gS rks vYiO;Ld nkosnkj dk fooj.k If the claimant is a guardian, details of the minor nominee/heir
vYiOk;Ld dk uke@Name of the minor
vfHkHkkod dk vYio;Ld ds lkFk lEca/k@Relationship of the
guardian with minor

3 nkosnkj dk iw.kZ Mkd irk LiV v{kjksa esa


Claimants Full Postal address (in block letters)

Jh@Jherh@ Shri./Smt..
lqiq=@/kEkZiRuh@ifr@iq=h@ Do/ S/o W/o H/o
.
. fiu@Pin.....................................

nkosnkj ds gLrk{kj@Signature of claimant


www.epfindia.gov.in

fu;ksDrk ds gLrk{kj@Signature of Employer


Page 1 of 4

4 jkfk Hkstus dh jhfr Mode of remittance:


eq>s lwfpr djrs gq, esjs cpr [kkrk la-vuqlfw pr cSad@Mkd?kj
esa js[kfdar psd bysDVkWfud ek/;e ls vknkrk [kkrk lh/ks Hkstk
tk,@ By account payees cheque/ electronic mode
sent Direct for credit to my S.B. A/C (Scheduled
Bank /PO) Under intimation to me

cpr cSad [kkrk la-@


S.B Account no..
CkSad dk uke@
Name of the Bank
kk[kk@Branch

kk[kk dk iwjk irk@ Full Address of the Branch..

nkosnkj ds gLrk{kj vFkok cka,@nk,a gkFk ds vaxwBs dk fukku)


(Signature or Left/Right hand thumb impression of the claimant)

vfxze iskxh jlhn


Advance Stamped Receipt
..--------------------------------------:i, dsoy --------------------------------------------------- :i, dh jkfk {ks=h; Hkfo; fuf/k vk;qDr@dk;Zdkjh vf/kdkjh mi{ks=h; dk;kZYk;
----------------------------------------------------------------------------------------- ds }kjk deZpkjh fu{ksi lgc) chek ;kstuk ykHkksa ds :i esa esjs cpr [kkrs esa tek ds fy, izkIr gq,A
*Received a sum of Rs(Rupees....................................................................only)
from Regional Provident Fund Commissioner/Officer-in-charge of sub Regional Office..............................by
deposit in my Saving Bank account towards the Employees Deposit Linked Insurance benefit.
LFkku {ks=h; Hkfo; fuf/k vk;qDr@dk;kZdkjh vf/kdkjh mi{ks=h;
dk;kZy; }kjk Hkjk tkus ds fy, [kkyh NksM+k tkuk pkfg,
*The space should be left blank which shall be filled in
by Regional Provident Fund Commissioner/Officer
incharge of S.R.O.

` 1 jktLo
fVdV
`
1
Revenue
Stamp
nkosnkj ds gLrk{kj vFkok cka,@nka, gkFk ds vaxwBs dk fukku
Signature or Left/Right hand thumb impression of the claimant

www.epfindia.gov.in

Page 2 of 4

izek.k&i=@ Certificate
(fu;ksDrk }kjk Hkjk tk, To be furnished by the Employer)
1 izekf.kr fd;k tkrk gS fd nkosnkj us esjs lkeus gLrk{kj@vaxwBk fukku fd;k gSA mijksDr fooj.k esjh iw.kZ tkudkjh ds vuqlkj iw.kZ;rk lR; gSA
Certified that the claimant is has signed/thumb impressed before me. I declare that the above particulars are true to the best of
my knowledge.
2- izekf.kr fd;k tkrk gS fd lnL; dh e`R;q lsokdky ds nkSjku fnukad dks -------------------------------------------------------------------------------------- gqbZA
Certified that the member died on.................................................. while in service.
3 izekf.kr djrk gwa fd e`rd Jh@Jherh@dqekjh ------------------------------------------------------------------------------------------------------------------------------[kkrk la[;k ------------------------------------------------------ dh Hkfo; fuf/k jkfk Jh@Jherh@dqekjh dks fn;k x;kA
Certified that the Provident Fund accumulation of deceased employee, late Sh/Smt./Kumari .......................
..................................................... A/c. No.............................................. were paid to Shri/Smt./Kumari
(i)
(ii)
(iii)
NwV izkIr izfrBku ds fu;kstd e`rd deZpkjh ds ukekadu izi= dks rlnhd@lk{;kdu izfr Hkstx
sa sA
(The employer of exempted Establishment shall send on attested copy of the nomination of the deceased employee)

lnL; dh e`R;q ds rqjUr iwoZ 12 eghuksa esa izR;sd ekg ds vUr esa lnL; ds Hkfo; fuf/k [kkrs esa ksk fooj.k /Balance in Provident Fund at
the end of the month, proceeding the 12 months immediately proceeding the death of the member
deZpkjh Hkfo; fuf/k ;kstuk 1952 ls NwV izkiz LFkkiuk }kjk Hkjk tk,@To be filled in by employee of establishment exempted under
EPF Scheme 1952.
dza- la-@
vaknku ds nksukas
fudklh /ku dh
C;kt@
fudklh@
mkjkskj ksk@
ekg@ Month
S.No
Interest
Withdrawals
Progressive
fgLls@ Both
okilh@ Refund
Balance
shares of
of withdrawal
Contribution
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
tksM+@Total
12 eghuksa dk tksM+
Total of 12 Months

Hkfo; fuf/k ksk `a----------------------------------------------------Provident Fund Balance `..............

vkSlr ksk ` .................................................


Average Balance ` .....................................

fu;kstd ds gLrk{kj dk;kZy; eksgj lfgr uke rFkk inuke


Signature of the employer (Name & designation with official Seal)
fnukad Date
#;fn ykxw u gks dkV nhft, Delete, if not applicable
fVIi.kh % vNwV izkIr izfrBkuksa ds fu;kstdksa }kjk dsoy LrEHk 2 Hkjk tkuk pkfg, vkSj NwV izkIr izfrBkuksa ds fu;kstdksa dks lHkh [kkus Hkjus pkfg,A
Note: The employer of un-exempted establishment should fill in the column 2 only and the employer of exempted
establishment should fill in the all columns.

Page 3 of 4

vk;qDr d;kZYk; ds iz;ksx gsrq


(For the use of Commissioners Office)
QkeZ 21&,@9 lakksf/kr 1 ch-fu- rFkk fudklh jftLVj esa ntZ dj fy;k gSaA
Entered in Form 21-A/9 (Revised) 1 I.F. withdrawal Register
lk-lq-lSSA

vuq- i;Z
SS

:i;s ds v/khu
(Under ` ......................................................................................................................)
Hkqxrku en la[;k
P. I. No.
[kkrk la[;k
Account No. ...
vuqHkkx
Section .....................
--------------------------------------------------------- ` ----------------------------------------------------------------------------------------------- dsoy :i, dh jkfk Hkqxrku ds fy, ikl dh xbZ rFkk jkfk
Jh@Jherh@dqekjh ----------------------------------------------------------------------- ds cpr cSad [kkrs esa tek ds fy, vnk dh tk, tksfd -------------------------------------------- cSad esa gSA
Passed for payment for `..................... (`.............................................................................) and the
amount may be remitted for credit to the Saving Bank Account No................. in respect of
Sh./Smt./Kumari ..............................maintained at ........... (Bank)

ys[kk vf/kdkjh@ Accounts Officer


fnukad@ Date: ..
psd la[;k ----------------------------------------------------------------------------------- ls lekosk }kjk Hkqxrku fd;k x;kA
Paid by inclusion in cheque No.

lk-lq-lSSA

vuq- i;Z
SS

l-vk-@{ks-vk
A.C/R.C

www.epfindia.gov.in

Page 4 of 4

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