FORM 20 - Employees' Provident Fund Organisation

JI1ITI'TlfJI/CERTIFICATE \;fliT (fCfj ~ Wof t 1f~ ~ T fcmIm~ t f...
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(For Office use only) .

~~~~.1952 EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 1WlI~20 FORM NO-20 >r
3.

\iIlo/TT Form to be used: ~
em By the guardian of minor /lunatic member By a nominee or legal heir of the deceased member. ~/~ ~ ~ m '3'i1~I~CIlI~
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I Note: Read the "Instruction" Carefully before completing the form. 1IiT flIlftIrr/Particulars of the member

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31effl -<1)/ Name of the member (In

(1) ~ 1l>T 'W{ ~ block letters)

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

(3) ~/~

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'{1l'I Cl" l«!T

Name

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I Name & Address of the Factory/ Establishment in

which the member was last employed

(4)
Account No.

(5) ~

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(6) ~

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1l>T ~

I Date ofleaving Service / Reason for leaving service ~

(7) ~

q\t ~/Date

(8) ~



"'i I (In case of deceased member)

of Death (ddlmm/yyyy) q\t ~

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~/Marital

status of the

member on the day ofhislher death

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$ ftlRvr Particulars of the Claimant

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Name of the claimant (in block

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

Husband's name

(3) fWT/Gender (4) ~

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q\t ~


Age(as on Date of death of

the

member), ~ ~ q\t ~ q\t ~ q;T)/Marital status (as on the date of death of member) (6) ~ ~
(5) ~

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$ ~/Signature

ofappIicant

Form 20 (www.epfindia.gov.in)

~

$ ~/Signature

of Employer Page 1 of4

~/~

~ cf; ~/lIiRrcf) 6RT 'Iffi ~ To be filled by the Guardian/Manager of MinorlLunatic member

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m/OR ~

(1)

cf; ~~ /~ ~(aT) cf; ~ m ~/ ~ ~ (lit)! ~ cf; ~ Guardian of LunaticlMinor Nominee(s)l Legal Heir (s) !Family member (s) of the deceased member

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6RT 'Iffi \ijJ1/1TT1

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(2) (3)

cf; ~
~/~ ~ ~/ ~ ~/~ Particulars of the MinorlLunaticINominee(s)lLegal


=s Date of

IWT

'WI Name

S.No

Gender

q'l

'H>q! Relationship

Relation

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~/With deceased member

~/ With Guardian

Birth

1 2 3 4

m or
"lift <'IT'l. 'f (4)


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Delete ifnot applicable

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Claimant's Full Postal address (in block letters)

/

Shri.lSmL..

~/~/~/~/

. S/o W/o RIo D/o

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...................................................

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(5)
qft ~ Mode of Remittance

fiR/Pin

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1I'I'~~~tjf.lmrl~ Put a tick in the box against the one opted

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By account

payees cheque/

electronic mode sent Direct for credit to my S.B. AlC (Scheduled BankIPO) under intimation to me (attA- ftt; ~"$ "fi1t/~ t
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Please attach a copy of cancelledlblank Cheque) ~

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Account

no

.

Name of the Bank

.

~/Branch

.

1ft

anl.1('l>.~. ~

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m
"$ flmlII'r/Signature

of appllcaat

Form 20 (www.epfindia.gov.in)

/ IFS Code


Full Address

.

of the Branch

f.I$mr" ~/Signature

.

of Employer

Page 2 of4

JI1ITI'T lfJI/CERTIFICATE \;fliT (fCfj ~ Wof t 1f~ ~ T fcmIm ~ t frr I To the best of my knowledge I assure that no Posthomous child will be born to the deceased member

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I certify that the minor member has not been employed in any FactorylEstablishment of not less than 2 months immediately preceding the date of this application

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aft<~

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to which the "Act" applies for a continuous period

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Enclosures

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~ 'ffiiIGnt

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f."mr;f

Signature or LeftlRight hand thumb impression of the claimant

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Date

vU £!PI

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err ij)JC

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"Delete if not applicable"

3lftm ~ $n;r ~

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ffi);r Advance Stamped Receipt [To be furnished only in case of5(b) above]

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Received a sum of (*t ('Rupees Regional Provident Fund Commissioner/Officer-in-charge of sub Regional Office. Bank account towards the settlement of Provident Fund accounts ofShri/Smt...

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only) from ' .by deposit in my Saving .

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

f 1 Revenue Stamp

~ T f.'mR Signature or LeftlRight hand thumb impression of the claimant

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Gm WII"N?T

Certificate by the attesting authority

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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

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(For the use of Commissioner's Office)

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artfWq;/lj',"f 'TfOR 1flIT q;fIf 21-1U 24/2/9 ~ om ~ ~ Tt d "" fRm ~ Nc Settled in Part/Full entered in Form 21-N2412/9 (Revised) and withdrawal Register

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aJ'j.tJ
SSA

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(Under ~

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>Al'ant. / $I> M.O'/Cheque

'TfOR 1fG ~

P.I.No. """"".,,""""""""

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Section """"""""""

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et; ~

'Iffi fcI>l.IT

Accounts No.

Passed for Payment for ~ .. " .. ". """,, ". ",,'"

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Accounts Officer

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Dated ~

3lJlWT

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(FOR USE IN CASH SECTION)

~ Paid by cheque No. " et;

mm ~-10

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Date

em

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" .. Vide cash book

1flIT I

(Bank) Account No. 3 Date item No.

35.1iIf

JSS

TI' 3lT./ ~.3lT/ APFCIRPFC

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REMARKS

Form 20 (www.epfindia.gov-in)

Page 4 of4