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1 ~" ~~<f; ~~ (ForOfficeuse only)GTCIT~ ~~~~.1952 EMPLOYEES'PROVIDENTFUNDSSCHEME,19521 WlI~20 FORMNO-20>r<fJT~~\iIlo/TTFormto be used:-1. ~/~~~<f; ~emBy the guardianof minor/lunaticmember2. ~~<f; ~/ ~~emBy a nomineeor legalheir of the ~/~~~m '3'i1~I~CIlI~<f; ~em~'1'fCIl-~<Ilt ~~ ~ c:W <f; ~By guardianof the minor/lunaticnomineeor heir for claimingthe ProvidentFundaccumulationof the minordeceasedmember~: ~ >r<fJTq;T 'i"f m <f m ~ ~~ I Note:Readthe "Instruction"Carefullybeforecompletingthe form.~1 IiT flIlftIrr/Particularsof the member(1)~1l>T'W{~31effl-<1)/ Nameof the member(Inblockletters)(2) fllin/'lfct1l>T 'W{/Father's/Husband'sName(3) ~/~q;r '{1l'I Cl" l !T ftR:IlI~3fflmm <i>TI!q;; IfI!UI Name& Addressof the Factory/Establishmentinwhichthe memberwaslast employed(4) <IDOT"ffi.}}}
2 <;!rr/AccountNo.(5) ~~<Ilt ~ I DateofleavingService(6) ~~1l>T ~/ Reasonfor leavingservice~~<f; ~"'iI (In caseof deceasedmember)(7) ~ q\t ~/Dateof Death(ddlmm/yyyy)(8)~ <f; ~ ~q\t ~~/Maritalstatusof thememberon the day ofhislherdeath~$ ftlRvrParticularsof the Claimant~~<f; cmq;~/~~/~<f; ~em1f'U\iIlo/TTITo be filledin by a Majornominee/legalheir/memberof the familyof the deceasedmember(I)<:TciGR<!iT 'W{~arero"'if Nameof the claimant(in blockletters)(2)fllin/'lfct1l>T 'W{/Father's/Husband'sname(3)fWT/Gender( 4)~~q\t ~<f; ~/Age(ason Dateof deathofthemember),(5)~~~q\t ~q\t ~q;T)/Maritalstatus(as onthe dateof deathof member)(6)~~<f; ~~/Re\ationshipwiththe deceasedmember~$~/SignatureofappIicant~$ ~/Signatureof EmployerForm20 ( )Page1 of4~/~~cf; ~/lIiRrcf)6RT'Iffi~ITo be filledby the Guardian/Managerof MinorlLunaticmemberm/OR~~cf; ~~/~~(aT)cf; ~m ~/~~(lit)!}}
3 ~cf; ~6RT'Iffi\ijJ1/1TT1 Guardianof LunaticlMinorNominee(s)lLegalHeir(s) !Familymember(s) of the deceasedmember(1) ~<IiT'WI(vitfcl;~m)Nameof the claimant( Guardian)(2)flmr/~<liT'WIFather's/Husband'sname(3)~/~~cf;~~Relationshipwithminor/deceasedmember~/~~~/~~/~cf;~<liTfimurftRrf;~ ~f.!IfEr~ <liTGJCITiIi"RT~IParticularsof the MinorlLunaticINominee(s)lLegalHeir(s)lSurvivingFamilyMemberson whosebehalfthe ProvidentFundAccountis claimed<!S."ff.'WIIWT=sq'l'H> <I>q! ~~<f;~<f;Birth~/With~/WithdeceasedGuardi anmember1234"lift <'IT'l. 'f m or <me~/Deleteifnotapplicable(4)~<liT'l"f ~ ' IT ~3lm't -.{)~ / ~ / 'sFullPostaladdress(in blockletters)~/~/~/~/S/o W/oRIo (5) <Tftr~ qft ~"W!Modeof Remittance1I'I'~~~ ~Put a tick in the box againstthe one opted(cI <Tftr~ ~ 'R ~qft "\ij"Jl;/(a) By PostalMoneyorderat my costDlJC:" ~4 cf; f<tqfuf~ t f 'RTo the addressgivenin <) ~ ~q;W~ ~ ~m<IT"ff.}
4 (~~/~)~ ~""'" .,<9'1j('if.'t "fl"'f'I"ff erremrm<IT~-.);;rr"\ij"Jl;//By accountpayeescheque/electronicmodesentDirectfor creditto (ScheduledBankIPO)underintimationto me(attA-ftt; ~"$"fi1t/~t<I; *~lIftr ~1ftPleaseattacha copyofcancelledlblankCheque)D~m<IT" <liT'WI/Nameof the Bank.~ ('l>.~.~/ IFSCode.~<liTwr ' IT/Full Addressof theBranch.~"$ flmlII'r/Signatureof $mr"~/Signatureof EmployerForm20 ( )Page2 of4JI1 ITI'TlfJI/CERTIFICATE\;fliT(fCfj~Woft 1f~ ~ <I>T fcmIm~t f<I;'lfI'P~~ ~cffll 'f"i%IT~"liftN>rr ITo the bestof my knowledgeI assurethat no Posthomouschildwill be bornto the deceasedmember1f~~q;l~~tf<l;~fmvT~'l"f~~ ~~'l"ffim~tlI certifythat the particularsgivenaboveare true to the bestof my knowledge1f~CffiITt f<I;~/~~~/~/~~ ~ ~ ffit/<ttt aft<~ Gm~~aft<~f<I;m\jff ffit mr ufr 'lftrm~~/~~~ ~~N \nl ~~ mu~*~W<f*t~1I certifythatthe minor(s).))
5 Is livingwithme andis beingsupportedand lookedfor by myselfand the FamilyPensionFundbenefitreceivedon behalfof minorIunaticwill be spentin hislherbestinterests& "EI'Ifur~t f<I;~~fil>flt~ ~/~if \iI5if<I;~~~aft<~~~~ ~ ~1!1$rrQ?[~ ~~ ~WlTcIR<IT lfm~ ~"lift1IR ffit II certifythat the minormemberhas not beenemployedin any FactorylEstablishmentto whichthe "Act"appliesfor a continuousperiodof not less than2 monthsimmediatelyprecedingthe dateof this application~/Enclosures~~ ~~ 'ffiiIGntmI!.f~ ~<I>T f."mr;fSignatureor LeftlRighthandthumbimpressionof the claimant~IDatevU !PI 'f ~ err ij)JC~"Deleteif not applicable"3lftm~ffi);rAdvanceStampedRec eipt$n;r~5(<<)~ ~if ~ uwfi~[To be furnishedonlyin caseof5(b)above]~ ..~ ..~ .. ~ ~:.~~.*.]
6 :..:::::::::::::::'.:'.::::::::::::::::: :::::::::::::'.': :..: :::..::..:..:..::.. ~~ ..~:r:. ~..~..~<~'lft/ ~I~~ 'j'fflR~if ~ 'I<rn~if \jflff~ ~~~ IReceiveda sumof (*t('Rupeesonly)fromRegionalProvidentFundCommissioner/Officer-in-chargeof sub ' .by depositin my SavingBankaccounttowardsthe settlementof 1 ffimf~f 1 RevenueStamp*~~~~ arrg<Rf/~~~~ ~~~~~\iIRT~*1bespaceshouldbe left blankwhichshallbe filledin ~<f; trmreR~'ll1iI<:lll'mI!.fet; ~<I>T f.'mRSignatureor LeftlRighthandthumbimpressionof the claimant~I~~GmWII"N?TCertificateby the attestingauthority~f<I;mumrrt f<I;\3i'R~~ mft t Certifiedthat the factsstatedaboveare correct.~f<I;mumrrt f<I;~'lftl ~/~q;l 1f3l<dt<m V!ROTt aft<~~ mJff~/~f."mr;ff<I;mt I Certifiedthat the knowntome and has signed/thumbimpressedbeforeme.)
7 ~/Date~m3Rr~~~~~mr~Signatureof the employeror any authorisedofficialdesignation& SealForm20 ( )Page3 of4~~~ lIliPrtw(Forthe use of Commissioner'sOffice)~ artfWq;/lj',"f'TfOR1flITq;fIf21-1U24/2/9 ~om ~~Tt d "" fRm~ INc Settledin Part/Fullenteredin Form21-N2412/9(Revised)and withdrawalRegisterm.~. ' <!SS~'$ ~(Under~'TfOR1fG ~ """"".,,"""""""">Al' $I> '/Cheque~~AccountsNo.~Section""""""""""~ '$ ~et; ~'IffifcI> Paymentfor ~.." .. ". """,,". ",,'"" .. """ .." ..AccountsOfficer~Dated~3lJlWTit WiM it ffi'ii (FORUSEIN CASHSECTION)~Paid by chequeNo. " """""Date"".. Videcash booket; mm ~-101fG 'W!~em f<l;m1flITI(Bank)AccountNo. 3 Dateitem ~REMARKSTI' ~.3lT/APFCIRPFCForm20 ( )Page4 of4)
