For office use only Regn.

No _________

EMPLOYEES’ PROVIDENT FUNDS SCHEME 1952

FORM - 20

Form to be used for claiming the Provident Fund accumulation of minor/lunatic/deceased member

(1) By the guardian of minor/lunatic member

(2) By a nominee or legal heir of the deceased member.
(3) By the guardian of the minor/lunatic nominee or heir for claiming
the provident fund accumulation of the minor deceased member
Note : Read the “Instruction” Carefully before completing this form.

PARTICULARS OF THE MEMBER

a) Name of the member ( in block letters) Employee

name

b) Father‟s / Husband‟s name –Father/spouse name

c) Name & Address of the Factory / Establishment in ERICSSON INDIA PVT Ltd.
which the member was last employed 3rd & 4th Floor Building 7A Phase 3 DLF
Cyber city Sec-25A Gurugram-122002.
d) Account No. PF account number.

e) Date of leaving service Date of Death

f) Reasons for leaving service DEATH

g) IN CASE OF DECEASED MEMBER Date of Death

Date of Death

h) Marital status of the member on the day of death Married/Un-married

PARTICULARS OF THE CLAIMANT

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) Nominee name

b) Father‟s / Husband‟s name Father/Husband name
c) Sex M/F
d) Age( as on the date of death of the member ) Age
e) Marital status ( as on the date of death of the Married/Unmarried
member whether unmarried, widow/widower)
f) Relationship with the deceased member Relationship with the Deceased member

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 To be filled in by the Guardian of Minor member/ 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
(c) Relationship with the member /deceased member

Particulars of the Minor/Lunatic ( Nominee(s)/Legal Heir(s)/ Family Member(s) on whose behalf the
Provident Fund Account amount is claimed

S.NO. NAME SEX AGE RELIGION RELATIONSHIP

WITH DECEASED MEMBER WITH GUARDIAN
1
2
3
4
* Delete if not applicable
4. Claimant‟s Full Postal address ( in block Shri/Smt./Kumari _________________________
letters
S/o,W/o, H/o, D/o_________________________
_______________________________________
Pin_____________________________________

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

(a) By Postal Money order at my cost To the address given against item No. 4
( payable upto Rs. 2,000/-only)
OR
(b) By account payee cheque sent direct for S. B. Account No.____Nominee Account Details
credit to my account in the Scheduled Bank/or
any post office or any co-operative Branch: Bank Name of the Bank__Bank Name___
including Urban Co-operative Bank. or any post
office under intimation to me) Advance Stamped Branch :___Bank Branch details_____
receipt furnished below [ ]
Full address of the Branch__Full address of Bank
(c) by deposit in the payee‟s name ( the whole or
part of the amount ) in the form of annuity term
deposits scheme in any Nationalised Bank [ ] ________________________________________

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 CERTIFICATE
To the best of my knowledge no posthomous child will be born to the deceased member

I certify that the particulars given above are true to the best of my knoweldge.

I certified that the minor(s) lunatic Sh. / Smt. / Kumari_______________________________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 interest and benefits.

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 2 months immediately preceding the date of this
application.

Signature of Left hand thumb impression of

the claimant
Enclosures :
Date
Delete, if not applicable

Advanced Stamped Receipts

[ To be furnished only in case of 5(b) above ]

Received a sum of ( Rs.*______________________(*Rupees________________________________

Only) from Regional Provident Fund commissioner/Officer – in – charge of Sub Regional office/Sub
–Accounts Office __________________________________________. By deposit in my Saving
Bank Account towards the settlement of my Provident Fund accounts of Shri / Smt. ______________
_______________________________________________

* The space should be left blank which

shall be filled in by Regional Provident
Fund Commissioner/ Officer In charge of Affix 1 rupee
S.R.O./S.A.O. Revenue stamp

Signature or Left hand thumb

impression of the claimant

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Certificate by the attesting authority – CONTRIBUTION FOR THE CCURRENT PERIOD

Contribution Contribution
Month Employee Employer Total Period Month Employee Employer Total Period
of of
EPF EPF EPS EPF EPS Break if
EPF EPF EPS EPF EPS Break if
any any

Certified that the above contribution have been included in the regular monthly remittances.
Certificate by the attesting authority
Certified that the facts stated above are correct.
Certified that the claimant Shri/Smt. Kumari______________________________________ is known
to me and the signed/thumb impressed before me.

Date
Signature of the employer or any authorised
Official Designation & Seal
( FOR THE USE IN PROVVIDENT FUND COMMISSIONER’S OFFICE )

A/c Settled in Part/Full entered in form 21-A/24/2/9 ( Revised) & withdrawal Register

Clerk S.S.
P.I. No.________________________ M/O/ Cheque Account No. ___________

Section __________________________
Under Rs. _________________________________________________________________________
Passed for payment for Rs. _________________( Rupees in words____________________only)

M.O. Commission ( if any)________________ A.A.O./ A.P.F.C.

Date
Net amount to be paid by M.O.____________

FOR USE IN CASH SECTION

Paid by inclusion in cheque No.__________________dated___________the_________vide Cash
Book Account No. 3 debit item No.____________________________________________________

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 S.S. Assistant Commissioner

REMARKS

INSTRUCTIONS
( FOR THE GUIDANCE OF APPLICANT ONLY, NOT TO BE SENT ALONGWITH THE CLAIMS)

The following instructions should be carefully read before completing the form

Employees‟ Provident Fund Scheme 1952 form No. 20

Claim for the withdrawal of provident fund accumulation of minor/lunatic/deceased members

By whom the claim application should be preferred

(1) If the member is minor by his guardian

OR
(2) On the death of the member :

(a) If a valid nomination subsists – by the Nominee (s) of the deceased member if
the nominee (s) is/are minor(s) guardian of the 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
husband are alive, of the deceased member duly supported by a list of surviving
family members ( as on date of death of the member ) furnished by the last
employer or mamladar/Tehsildar or Executive Magistrate, indicating complete
particulars such as name, relationship with the deceased member ( in the case of
parents‟s whether dependent or not ) age, Marital status.

If any family member is minor by the guardian of the 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
authorized)

3. Documents to be enclosed

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

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 (c) If the amount receivable exceeds Rs. 5000/- but less than Rs. 25000/- an
affidavit-cum-indemnity bond ( from may be obtained from the ex-
employer or Regional Provident fund Commissioner or Officer-in- charge
of sub-Regional Office____________________________) or Estate duty
clearance certificate.
(d) If the amount receivable exceeds Rs. 25000/- an Estate duly clearance
certificate
Form – 11 ( F.P.F.) claim for benefits as admissible under Employees
Pension Scheme, 197
By whom the claim application should be preferred

1. If the member is minor by his guardian

OR
2. On the death of the member

(i) If the deceased member 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 of eldest surviving minor son
(c) failing (a) and (b) above by the guardian of eldest surviving
minor unmarried daughter.
(ii) If the deceased member had to family on the day of death family
pension benefits should be claimed by the person(s) eligible to receive
the Provident Fund Accumulations of the deceased 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 2 years, an application in
form 10-A should also be preferred for claiming monthly Family pension.

(iii) Form 5 ( I.F..) Benefits under Employees‟ Deposit Linked Insurance

Scheme 1976

The benefits 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 condition

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

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

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(3) An affidavit-cum-indemnity bond is the prescribed form should be furnished
wherever the payment under Employees‟ Deposit-linked Insurance exceeds
Rs. 5000/- ( if amount receivable under employees‟ Provident and
Employees‟ Deposit-Linked Insurance does not exceed Rs. 25000/- one
affidavit-cum-indemnity bond is sufficient.)

General

(1) All the columns in the form should be filled in ink, without any
overwriting
(2) Correct Postal address, including the PIN code will enable to make
prompt Payment to the correct payee.
(3) The Claimant should also furnish the address in the acknowledgement
card 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

member was last employed. If for reason, the claimant is unable to submit
through the employer, the claim may be got attested with official seal by any
of the following officials.
(i) Magistrate
(ii) A Gazetted Officer
(iii) Post/Sub-Post Master
(iv) President of village union
(v) President of the village Panchayat where there is not 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 E.P.F.
(ix) Manager of the Bank in which the Saving Bank Account is
maintained.
(x) Head of any recognized educational institution
(xi) Any other official as may be approved by the Commissioner.

(6) Instructions to Employers

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While forwarding the claims, the employers should ensure that all the
information required is the claim is furnished correctly and requisite
documents are enclosed.

In support of claim under Employees‟ Family Pension Scheme 1971 the

period of break in reckonable service i.e. period for which F.P.F.
contribution not payable should be furnished, if not already intimated
through Contribution Card.