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

    Uploaded by

    savideshwal
    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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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

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

    Uploaded by

    savideshwal
    46 views4 pages
    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.

    Original Description:

    Form IF

    Original Title

    Form5IF

    Copyright

    © Attribution Non-Commercial (BY-NC)

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    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    46 views4 pages

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

    Uploaded by

    savideshwal
    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 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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