Sample Filled EPF Form 10c

Relationship

With the member

With the guardian

Please find attached Forms 10D and 20 with another file of Form 20 with instructions to filled up.

Employees Provident Fund Scheme

Form 20

Employees’ Provident Funds Scheme, 1952

Form to be used :

(1) by guardian of minor/lunatic member.

(2) By a nominee or legal heir of the deceased member.

Or,

(3) By the guardian of the minor/lunatic nominee or heir.

For claiming the Provident Fund accumulation of minor/deceased member.

Particulars of Member

(a) Name of the member (in Block Letters)

(b) Father’s / Husband’s Name

in which the member was last employed

(d) Account No.

(e) Date of leaving service

(f) Reason for leaving service (in case of deceased member)

(g) Date of death of the member

(h) Marital status of the member on the day of death

Particulars of the claimant

1. (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

(d) Age (as on the date of death of the member)

(e) Marital status (as on the date of death of the member)

(Whether unmarried, married, widow, widower)

(f) Relationship with the deceased member.

* 3 To be filled by the Guardian/Manager of Minor/Lunatic Member or Lunatic Minor

{Nominee[s]/Legal Heir[s]/Family member[s] }

of the deceased member

(a) Name of the claimant [i.e. Guardian]

(b) Father’s / Husband’s Name

*3 Particulars of the minor/Lunatic Nominee(s) Legal Heir(s) / Family Member(s) on whose behalf the Provident Fund Amount claimed.

* Delete, if not applicable

2. Claimant’s Full Postal Address (in Block Letters)

Shri/Smt………………………………………………………………….

S/o / W/o / H/o / D/o ……………………………………………….

…………………………………………………………………………….

……………………………………………………………………………

PIN………………………………………………………………………..

3. MODE OF REMITTANCE

(a) by postal money order at my cost, or

(b) by account payee cheque sent direct for credit to my S.B. A/c (Sch. Bank/Post Office ) under intimation to me (Advance Stamped Receipt) furnished below :

Put a ‘tick in the box against the one opted [ 3]

* to the address given in Item No. 4

* S.B. Account No. ………………………………….

Bank…………………………………………………..

Branch………………………………………………..

Full address of Bank…………………………………

…………………………………………………………

Certificate

*To the best of my knowledge no posthumous child will be born to the deceased member.

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 interests and benefit.

I certify that the minor member has not been employed in any Factory/Establishment to which the Act applies for a continuous period of not less than 6 months immediately preceding the date of the application.

Enclosure

Signature of left/right hand thumb impression of the claimant

Date

Delete if not applicable.

Advance Stamped Receipt

[To be 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…………. By deposit in my Saving Bank Account towards the settlement of Provident fund Account of Shri/Smt…………………

* The space should be left blank which Affix

shall be filled in by RPFC/Office-in-Charge 1 Rypee

of S.R.O. Revenue

Stamp

Signature of left/right hand thumb impression of the claimant

Certificate of the attesting authrority

Contribution for the Current period

Month	Contribution			Period of break if any	Month	Contribution			Period of break if any
	Employee	Employer	Total
	EPF FP	EPF FP	EPF FP			EPF FP	EPF FP	EPF FP




Certified that the above contributions have been included in the regular monthly remittances.

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 employer or authorised officer Designation & Office Seal

For the use of Commissioner’s Office

Account settled entered in Form 21-A/24/2/9 (Revised) & Withdrawal Register.

Clerk Head Clerk

P.I. No. ……………… M.O. Cheque Account No…………….

Section………………………………….

Passed for Payment Rs……………….

(In words)……………………………………………………………..

M.O. Commission (if any) Accounts Officer

Net amount to be paid by M.O. Date

Under Rupees………………………………..

For use in Cash Section

Paid by inclusion in Cheque No. ……………………………. Vide Cash Book (Bank Account No. 3 Debit Item No. ………………………………

Head Clerk Assistant Commissioner/Regional Commissioner

Remarks

ACKNOWLEDGEMENT CARD

Account No. Office of the RPFC/Officer-in

EPFO Charge of Sub-Regional Office

ACKNOWLEDGEMENT CARD

Received the following claims. Registration No………………………

Date Office Seal……………………..

………………………………………….

POST CARD Postage

Prepaid

In case, no intimation is received within a month, you may write to the Compliants Officer, Employees’ Provident Fund duly quoting the Registration Number and your Provident Fund Account Number.

………………………………………………………………………………………………

PIN………………………………………………………………………………………….

EMPLOYEES’ PROVIDENT FUND ORGANISATION

Office of the Regional Provident Fund Commissioner / S.R.O……………………

Full Address………………………………………………………………………………

Instruction

(For the guidance of applicant only, not to be sent along with the claim)

The following instruction should be carefully read before completing the form.

1. Employees’ Provident Fund Scheme, 1952 : Form 20: Claim for the withdrawal of Provident Fund Accumulation of minor/deceased member.

By whom the claim application should be preferred?

2. If the member is a minor by the guardian.

On death of the member :

(a) If nomination subsists : by the nominee(s) if the nominee(s)/are minor by the guardian of minor(s).

(b) If no nomination subsists : – by the family member’s (family includes posthumous child if any, except major sons, and married daughters whose husbands are alive, of the deceased member duly supported by list of surviving family members (as on the date of the death of the member) furnished by the last employer or mamlatdar/Tehsildar or Executive Magistrate indicating complete particulars such as name, relationship with deceased member (in the case of parents whether dependant or not) age, marital status. If any family member is a minor by the guardian of minor.

If both (a) & (b) above are not applicable : – by legal heir(s) duly supported by a legal heirship certificate (from the appropriate State Normally Revenue authorities).

3. Documents to be enclosed :

(a) If the application is preferred by a guardian other than the natural guardian or minor member/nominee/family member/legal heir a guardianship certificate issued by competent court of law should be enclosed.

(b) Death certificate.

(c) If the amount receivable exceeds Rs. 5000 but less than 25,000 an affidavit-cum-indemnity bond (From may be obtained from the ex-employer of Regional Provident Fund Commissioner or Officer-in-Charge of Sub-Regional Office ……………………) or Estate Duty Clearance Certificate.

(d) If the amount receivable exceeds Rs. 25,000 on Estate Duty Clearance Certificate.

Form 11 (FPF) : Claim for benefits as admissible under the Employee’s Pension Scheme, 1971. By whom claim application should be preferred ?

(1) If the member is minor by his guardian.

(2) On death of the member :

(i) If the deceased had ‘family’ on the day of death the claim should be preferred by.

(a) the widow or widower.

(b) Failing (a) above, by the guardian or eldest surviving minor son.

(i) If the deceased member had no family on the day of death, the Family Pension Fund benefit should be claimed by the person(s) eligible to receive the Provident Fund accumulation of the dece3ased member and if such member is a minor by the guardian. *(If the claimant being other than the natural guardian a guardianship certificate issued by the court of law should be enclosed.

Important Note : – In case the member died while in service after contributing to the Family Pension Fund for a period of not less than two years, an application in Form 10-A should also be preferred for claiming monthly Family Pension.

(iii) Form 5(F) ‘Benefit under Employees’ Deposit-Linked Insurance Scheme, 1976.

The benefit under Employees’ Deposit-Linked Insurance Scheme, 1976 is admissible to the person(s) entitled to receive the Provident Fund accumulation of the deceased member only under the following conditions.

(1) The death should have occurred while in service and.

(2) The average balance in the accounts of the deceased employees should not be below the sum of Rs. 1000 during the preceding three years of during the period of his membership, whichever is less.

An affidavit-cum-indemnity bond in the prescribed form should be furnished wherever the payment under Employees’ Deposit-Linked Insurance exceeds Rs. 5000 (if amount receivable under Employees’ Provident Fund and Employees’ Deposit-Linked Insurance does not exceed Rs. 25,000 one affidavit-cum-indemnity bond is sufficient).

GENERAL

(1) All the columns in the form should be filled in, in ink, without any overwriting.

(2) Correct postal address, including PIN CODE will enable to make prompt payment to the correct payee.

(3) The claimant should also furnished the address in the acknowledgement attached to the claims.

(4) The literate claimant should sign the application form.

In case of illiterate : – Left hand thumb impression by illiterate male claimant and right hand thumb impression by illiterate female should be affixed in the claim form.

(5) Attestation of claim application : – The application should be submitted through the employer under whom the member was last employed if for any reason the claimant is unable to submit through the employer, the claim may be got attested with official seal by any one of the following officials. (I) Magistrate; (ii) A gazetted officer; (iii) Post/Sub-Postmaster; (iv) President of Village Union; (v) President of the Village Panchayat where there is no Union Board; (vi) Chairman/Secretary/Member of the Municipal/District/Local Board; (vii) Member of Parliament/Legislative Assembly; (viii) Member of C.B.T. Regional Committee of the E.P.F.; (ix) Manager of the Bank where claimant has account; (x) Head of any recognised educational institution or ; (xi) Head of any recognised educational institution or; (xi) Any other official as may be approved by the Commissioner.

(6) Instruction to employers :

While forwarding the claims the employer should ensure that all the information required in the claim furnished correctly and requisites documents are enclosed in support of claim under Employees’ Family Pension Scheme, 1971 the period of break in reckonable service (i.e. period for EPF contribution is not payable should be furnished, If not already intimated through contribution card.

For office use only

Dated Official Seal and

Registration No. …………………………

Click Here to Download Format PFF20