I I I I - Employees' Provident Fund Organisation

1 ~ <: ~ ~1ftwn"~.1978 THEEMPLOYEES'DEPOSIT-LINKEDINSURANCESCHE ME,1976~~iI"RT3rof1T~om ~,~ ~~ ~t <IT \ffiif;~iI"RTom ~,~ ~ amtCf;~~mol <lit ~1) ~EiRT~ lffiI"Iffl~,To be filledup separatelyby casethe claimantis minorit shouldbe filledup by the guardianon morethanone minorthe guardianshouldclaimin one Formon ~ JmT CJit ' ~ m .~ CJit ~~,Note- Readthe "Instructions"carefullybeforecompletingt hisform1. ~~<liT fcm1 JrThe Particularsin respectof the deceasedmember t;) ~~<IiT~(a) NameoftheDeceasedmember g) fimT <liT 'Ill{ ("qfct <liT 0f11i~~~ l!T'ffi"4)(b) Father'sName(Husband'snamein the caseof marriedwoman)(tr) ~~~I(c) Dateof Death(ddlmmlyyyy)I111111111~) ~/~<liT 'Ill{Cl"lffiT~~ ""ijR m /(d) Nameand Addressof the Factory!}}

2 Establishmentwherethe memberwas last employed.~)~M~~ <IiT.<Ii1'.~~$ (e) ~/~<liT fcm1Jr/Detailsof the claimant/guardian. t;) OfJ1!"/Name g) WI'I~/Dateof Birth(ddlmrnlyyyy)(tr) ~~ ~ ~/Relationwiththe deceased~fcm"uJIfthI d d 1 ftheIh~<liTe calmantIS a guarran,etalsoe mmornomineeir~<liT 'Ill{/Nameof the minor~<liT ~~ ~~/RelationshipoftheguardianwithminorCla imant'sFull Postaladdress(in blockletters).,fi/~ ~/~/tlfct/~/Dol S/o ~~ ~/Signatureof <J)qffi~ ~/Signatureof EmployerForm5IF ( )Page1of44 ~~cm ffit Modeof remittance:~ ~q;<ff~ ~ iffl{f<lIT<IT'fi.(~~/~)Tj~~ li~itl:lf'lq;1Jm11fif anmrr<lIT<IT~"4;m\iJT1?}}

3 /By accountpayeescheque!electronicmodesent Directfor creditto my (ScheduledBankIPO)Underintimationto me~~<lIT<IT' Accountno.~q;J YIfIl/Nameof the Bank.(~"-lIM"$ ~/~~ 11fT~ 1 Iftt.~ill\" Pleaseattacha copyofcancelled/blankCheque) ;J WT mrr/FullAddressof the Branch.~<6 mTeR3f~~/zy:!~ ~ ~q;J fuJR)(Signatureor Left/Righthandthumbimpressionof the claimant)~~. ~~~)cm~~~~~/~~~1!iflIh; ~ imT~~~;j)1:rr"lit\iAT"Rl"ll<6 <'it!"I'(~ ~mff"l'(Vf'lT<6 ~ >rJ1{f~I*Receiveda sumofRs('Rupeesonly)fromRegionalProviden tFundCommissioner/Officer-in-chargeof sub RegionalOfficebydepositin my SavingBankaccounttowardsthe Employees' DepositLinkedInsurancebenefit. }

4 ~~/~6""RT'lffi~<6 ~ <mft~\i!RT~*Thespaceshouldbe left blankwhichshallbe filledinby ~1 ~~~RevenueStamp~<6 ~~"iIttl"/GiII~ <6 ~q;J fuJRSignatureor LeftlRighthandthumbimpressionof the claimantForm5IF ( )Page2 of4lI'fI1If-~/Certificate(f.\ltIlImJm'RI' 'GIl1lTo be furnishedby the Employer)1 ~f<I>mWffit ~ ~;l~~~/~ 'If<I>m~I ~~~ <rT~if; ~~~tlCertifiedthat the claimantis has signed/thumbimpressedbeforeme. I declarethat the aboveparticularsare trueto the bestofmy ~fcl;mWffi~fcl;~q\)~~~~~q;f~ICertifiedthat the memberdiedonwhilein ~<tRmiifcl;~~/~/~.mm~q\) ~~~~/~/~om ~ 'lmlCertifiedthat the ProvidentFundaccumulationof deceasedemployee,late (i)(ii)(iii)W >IT'<!

5 ~if; ~'F"" ~if; 'W!i<IR"!l'EiIcm ~ /~"\!fa ~I(Theemployerof exemptedEstablishmentshallsendon attestedcopyof the nominationof the deceasedemployee)~q\) ~ if; ~~ 12 ~it ~ 1lrn"if; 3Rf~ ~if; ~~ri -.'j it'! f<t<R"I!Balancein ProvidentFundatthe end of the month,proceedingthe 12 monthsimmediatelyproceedingthe deathof the member~~~~1952"W mll~am 'ffi\iIf\//Tobe filledin by employeeof establishmentexemptedunderEPFS cheme1952.~. " "/ Month3tmFI<t; GFrr~1\Rq';ti!ITGI/~/~ ~/Both'Il"'Rfi/ RefundInterestWithdrawalsProgressiveshar esofof ~/Total12 lIMq;r iiI'R?Totalof l2 Months~~it'! ~it'!~.AverageBalance~.

6 ~~ ~~~ ."IT'!0l!.TT'IG'flll)Signatureof the employer(Name& designationwithofficialSeal)~Date#~~ ~ it q;rc~Delete,if not applicable~: 3lW>IT'<!~if; ~am ~ ~ 2 'ffi\ifAT~aft< W m'<f ~if; ~cm 'ff4t R~~INote:Theemployerof un-exemptedestablishmentshouldfill in the column2 onlyand the employerof exemptedestablishmentshouldfill in the all ( )Page3 of4(~iIRlf<;rq<f; wWr ~(Forthe use of Commissioner'sOffice)q;fl\21-11/9~)1 < ~~1\ G\it~ ~~ IEnteredin Form21-N9(Revised) withdrawalRegister~.~~.SSA~<f;~(Underr)"T"fR>!G msmP.!' ~ ~~~<CI~"T"fR~~'Im<CI~ ~~/~/~<f; ~le!; ~ 1\ \ijlff~ ~am <Cl\jffI;[Wf1I;le!]

7 ; >'i t IPassedfor paymentfor ~~,) and theamountmaybe remittedfor creditto the SavingBankAccountNoin (Bank)~ ~IAccountsOfficer~IDate:.$I; ~'ff ~bRT"T"fRfcI;m'l<ITIP aidby inclusionin ~~.SSA~~SSX' ( )Page4 of4