~"fi.

/ Mobile Number

~ ~ <f; ~ ~ (For Office use only)

GTCIT ~/Clam I.D .

~~~~.1952
EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
1WlI~20
FORM NO-20

>r<fJT
~ ~ \iIlo/TT Form to be used: -
1. ~/~~ ~ <f; ~em By the guardian of minor /lunatic member
2. ~ ~ <f; ~ / ~ ~ em
By a nominee or legal heir of the deceased member.
3. ~/~ ~ ~ m '3'i1~I~CIlI~ <f; ~ em ~ '1'fCIl-~ <Ilt ~ ~ ~ c:W <f; ~
By guardian of the minor/lunatic nominee or heir for claiming the Provident Fund accumulation of the minor deceased member

~ :~ q;T 'i"f
>r<fJT m <f m ~ ~ ~ I Note: Read the "Instruction" Carefully before completing the form.
~ 1IiT flIlftIrr/Particulars of the member

(1) ~ 1l>T 'W{ ~ 31effl -<1)/ Name of the member (In

block letters)

(2) fllin/'lfct 1l>T 'W{/ Father's/Husband's Name

(3) ~/~ q;r '{1l'I Cl" l«!T ftR:IlI ~ 3fflm m <i>TI!

q;;«If I!U I Name & Address of the Factory/ Establishment in
which the member was last employed

(4) <IDOT"ffi.<;!rr/ Account No.

(5) ~ ~ <Ilt ~ I Date ofleaving Service

(6) ~ ~ 1l>T ~ / Reason for leaving service

~ ~ <f; ~ "'i I (In case of deceased member)

(7) ~ q\t ~/Date of Death (ddlmm/yyyy)

(8) ~ <f; ~ ~ q\t ~ ~/Marital status of the

member on the day ofhislher death

~ $ ftlRvr Particulars of the Claimant

~ ~ <f; cmq; ~/~ ~/ ~ <f; ~ em 1f'U \iIlo/TTI
To be filled in by a Major nominee /legal heir/member of the family of the deceased member

(I) <:TciGR <!iT 'W{ ~ arero "'if Name of the claimant (in block
letters)

(2) fllin/'lfct 1l>T 'W{/Father's/ Husband's name

(3) fWT/Gender

(4) ~ ~ q\t ~ <f; ~/ Age(as on Date of death of the

member),
(5) ~ ~ ~ q\t ~ q\t ~ q;T)/Marital status (as on
the date of death of member)
(6) ~ ~ <f; ~ ~/Re\ationship with the deceased
member

~ $ ~/Signature ofappIicant ~ $ ~/Signature of Employer

Form 20 (www.epfindia.gov.in) Page 1 of4

 ~/~ ~ cf; ~/lIiRrcf) 6RT 'Iffi ~ I
To be filled by the Guardian/Manager of MinorlLunatic member
m/OR
~ ~ cf; ~~ /~ ~(aT) cf; ~ m ~/ ~ ~ (lit)! ~ cf; ~ 6RT 'Iffi \ijJ1/1TT1
Guardian of LunaticlMinor Nominee(s)l Legal Heir (s) !Family member (s) of the deceased member

(1) ~<IiT'WI(vitfcl;~m)
Name of the claimant (i.e. Guardian)
(2) flmr/~ <liT'WI
Father's/Husband's name
(3) ~/~~cf;~~
Relationship with minor/deceased member

~/~ ~ ~/ ~ ~/~ cf; ~ <liTfimur ftRrf; ~ ~ f.!IfEr~ <liTGJCITiIi"RT ~I

Particulars of the MinorlLunaticINominee(s)lLegal Heir(s)lSurviving Family Members on whose behalf the Provident Fund Account is claimed

<!S."ff.
S.No
'WI
Name
IWT
Gender
=s
Date of
q'l
Relation
'H><I>q! Relationship
~~<f; ~<f;
Birth ~/With ~/ With
deceased Guardian
member
1

"lift <'IT'l. 'f m or <me ~/ Delete ifnot applicable

(4) ~ <liT'l"f ~ '«IT ~ 3lm't -.{) ~ /~ / Shri.lSmL.. .

Claimant's Full Postal address (in block letters) ~/~/~/~/ S/o W/o RIo D/o .

................................................... fiR/Pin .

(5) <Tftr~ qft ~ "W! 1I'I'~~~tjf.lmrl~

Mode of Remittance Put a tick in the box against the one opted

(cI» <Tftr~ ~ 'R ~ 4 cf; f<tqfuf ~ t«f 'R

qft "\ij"Jl;/
(a) By Postal Money order at my cost D lJC:" ~
To the address given in item No.4

m/OR

«<) ~
~ ~
~ q;W ~ ~ ~ m<IT "ff.(~
""'" .,<9'1j('if.'t ••• "fl"'f'I "ff erremr
~/~) D
m<IT ~ -.);;rr "\ij"Jl;// By account payees cheque/ ~ m<IT "ff./S.B Account no .
electronic mode sent Direct for credit to my
S.B. AlC (Scheduled BankIPO) tcP <liT'WI/ Name of the Bank .
under intimation to me
(attA- ftt; ~"$ "fi1t/~ t<I; lIftr· *~ ~/Branch .
~ Please attach a copy of
1ft
cancelledlblank Cheque) anl.1('l>.~. ~ / IFS Code .

~ <liTwr '«IT/ Full Address of the Branch .

~ "$ flmlII'r/Signature of appllcaat f.I$mr" ~/Signature of Employer

Form 20 (www.epfindia.gov.in) Page 2 of4

 JI1ITI'T
lfJI/CERTIFICATE

\;fliT (fCfj ~ Wof t 1f~ ~ <I>T fcmIm ~ t f<I;'lfI'P ~ ~ ~ cffll 'f"i%IT ~ "lift N>rr I
To the best of my knowledge I assure that no Posthomous child will be born to the deceased member
1f~~q;l~~tf<l;~fmvT~'l"f~~~~'l"ffim~tl
I certify that the particulars given above are true to the best of my knowledge

1f~ CffiIT t f<I;~/~ ~ ~/~/~ ~ ~ ~ ffi

t/<tt t aft<~ Gm ~ ~ aft<~ f<I;m\jff ffi t mr ufr 'lftrm ~ ~ /~ ~ ~ ~ ~ N \nl ~ ~ mu
~*~W<f*t~1
I certify that the minor(s)/ lunatic Sh.lSmt.lKumari... ... ... . .... is living with me and is being
supported and looked for by myself and the Family Pension Fund benefit received on behalf of minor Iunatic will be spent in hislher best interests &
benefits.

1f "EI'Ifur ~ t f<I;~ ~ fil>flt ~ ~/~ if \iI5i f<I;~ ~ ~ aft<~ ~ ~ ~ ~ ~

1!1$rr Q?[ ~ ~ ~ ~ WlTcIR <IT lfm ~ ~ "lift 1IR ffi tI
I certify that the minor member has not been employed in any FactorylEstablishment to which the "Act" applies for a continuous period
of not less than 2 months immediately preceding the date of this application

~/ Enclosures ~ ~ ~ ~ 'ffiiIGnt mI!.f ~ ~ <I>T f."mr;f

Signature or LeftlRight hand
thumb impression of the claimant

~I Date
vU £!PI 'f ~ err ij)JC ~ "Delete if not applicable"

3lftm ~ ffi);r Advance Stamped Receipt

$n;r ~ 5(<<)~ ~ if ~ uwfi ~ [To be furnished only in case of5(b) above]

~
'lft/ ~
..~
I
..~ .... ~ ~:.~~.*.:::::::::::::::::::::::
..:..:::::::::::::::'.:'.::::::::::::::::::::::::::::::'
~~
: :..: :::.:.:..' .. ..:..:..:
f.l1tr 'j'fflR ~
:.. ~~ ..
if ~ 'I<rn ~ if
~:r
:. ~..
~..~<~
\jflff ~ ~ ~ ~ I
Received a sum of (*t ('Rupees only) from
Regional Provident Fund Commissioner/Officer-in-charge of sub Regional Office. . ' .by deposit in my Saving
Bank account towards the settlement of Provident Fund accounts ofShri/Smt... . .

*~ ~ ~ ~ arrg<Rf/~ ~ ~ f 1 ffimf
~Gm-.R~~~~~\iIRT~ ~
*1be space should be left blank which shall be filled in by f 1 Revenue
Regional Provident Fund Commissioner/Officer in-charge of Stamp
S.R.O.

~ <f; trmreR ~ 'll1i I<:lll' mI!.f et; ~ <I>T f.'mR

Signature or LeftlRight hand thumb impression of the claimant

~ I~ ~ Gm WII"N?T Certificate by the attesting authority

~ f<I;mumrr t f<I;\3i'R~ ~ mft t Certified that the facts stated above are correct.
~ f<I;mumrr t f<I;~ 'lftl ~/~ q;l 1f3l<dt <m V!ROTt aft<~
~ mJff ~/~ f."mr;f f<I;mt I Certified that the claimant ShrilSmt.lKumari is known to
me and has signed/thumb impressed before me.

~/Date ~m3Rr~~~~~mr~
Signature of the employer or any authorised official designation & Seal

Form 20 (www.epfindia.gov.in) Page 3 of4

 ~ ~ ~ lIliPr tw
(For the use of Commissioner's Office)

~ artfWq;/lj',"f 'TfOR 1flIT q;fIf 21-1U 24/2/9 ~ om ~ ~ Tt d "" fRm ~ I

Nc Settled in Part/Full entered in Form 21-N2412/9 (Revised) and withdrawal Register

m.~.TI. aJ'j.tJ<!
SSA SS

~ '$ ~ (Under ~

'TfOR 1fG ~ >Al'ant. / $I> ~~

P.I.No. """"".,,"""""""" M.O'/Cheque Accounts No.

~ Section """""""""" ~ '$ ~ et; ~ 'Iffi fcI>l.IT Passed for Payment for ~ .. " .. ". """,, ". ",,'" " .. """ .." ...

Accounts Officer
~
Dated

~ 3lJlWT it WiM it ffi'ii (FOR USE IN CASH SECTION)

~
Paid by cheque No. " " "" "" Date " " .. Vide cash book
et; mm ~-10 1fG 'W! ~ em f<l;m 1flIT I
(Bank) Account No. 3 Date item No.

35.1iIf JSS TI' 3lT./ ~.3lT/ APFCIRPFC

~
REMARKS

Form 20 (www.epfindia.gov-in) Page 4 of4