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Employees’ Provident Fund Organisation

(Ministry of Labour & Employment, Govt. Of India)

Head Office

Bhavishya Nidhi Bhawan, 14-Bhikaiji Cama Place, New Delhi-110066

www.epfindia.gov.in , www.epfindia.nic.in
Telephone: 011- 26172685 Fax: 011-26173022 Email: rc.fa@epfindia.gov.in

No. Manual/Amendment/2011/Pt/163

Date: 03 MAR 2017

ORDER

[In the matter of Introduction of a Composite Claim Form in Death Cases to replace
existing claim Form-20, 10-D and 5-IF]

Employees’ Provident Fund Organisation has embarked upon its next phase of e-governance reforms with a view to make its services available to all its stakeholders in a more efficient and transparent manner.

2. The Central Provident Fund Commissioner vide order Manual/Amendments/2011/ Pt/31792 dated 20.02.2017 has introduced Composite Claim Form (Aadhar) and Composite Claim Form (Non-Aadhar) by replacing the erstwhile Forms No. 19, 10C & 31 to simplify the submission of claim form by the subscribers.

3. Pursuant to the provisions of paragraph 72(5)(c) of the Employees’ Provident Funds Scheme, 1952, paragraph 38 of Employees’ Pension Scheme, 1995 and paragraph 24(1) of the Employees’ Deposit-Linked Insurance Scheme, 1976, Central Provident Fund Commissioner hereby prescribes Composite Claim Form in Death cases by replacing existing Forms 20, 5-IF and 10-D. In case of death of a member, the claimant may apply for claim of provident fund, insurance fund and monthly pension in this single form.

(Dr. V.P. Joy)

Central Provident Fund Commissioner

EMPLOYEES’ PROVIDENT FUND ORGANISATION

Composite Claim Form in Death Cases
[Form-20 (PF Payment)/Form-10-D (Pension), Form – 5 IF (EDLI)]

1 Tick whichever is/are applicable (i) Provident Fund ( ) (ii) Pension ( )
Type of Pension claim:
(iii) Insurance [EDLI] ( )
2 Name of the deceased member (in CAPITAL letters)
3 (a) Father’s Name :

(b) Spouse’s Name :

a)

b)

4 Marital status of deceased member
5 a) Aadhar Number of the deceased member (if available)
b) Universal Account Number (UAN)
c) PF Account Number (in case UAN not available)
6 Date of Leaving service
7 Period of Non-Contributory service (Year/Month/Days)
8 Date of death of the member
9 Whether the member had died while in service(Yes / No)
CLAIMANT’S DETAILS FOR PROVIDENT FUND, PENSION AND INSURANCE (EDLI)
10 Particulars of the claimant/minor/nominee(s)/legal heir(s)/surviving family member on whose behalf the claim is submitted
s.

N.

Name Father’s / Spouse’s Name Aadhar Number Gender Date of Birth Marital Status Relationship with
Member Guardian
i
ii
III
iv
V
11 Bank Account details for payment of PF & EDLI:

(Please attach a copy of cancelled cheque/attested copy of first page of bank Pass Book)

Saving Bank Account No.

…………………………………………………………….

Name & address of the Bank

…………………………………………………………….

IFS Code……………………………………………….

BANK ACCOUNT DETAILS FOR PENSION
12 Bank Account details for payment:

(Please attach a copy of cancelled cheque/attested copy of first page of bank Pass Book)

Saving Bank Account No.

………………………………………………………..

Name & address of the Bank

………………………………………………………….

………………………………………………………….

IFS Code……………………………………………..

13 Full Postal address of claimant

Pin……….

Certified that the particulars are true to the best of my knowledge.

Employer’s Signature
Designation & Seal of Employer

Claimant’s signature

Name: …………………….

Enclosures:

i) Death Certificate

ii) Joint photograph of all the claimants

iii) Date of Birth certificate of children claiming pension

iv) Scheme Certificate (if applicable)

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Tags : EPF (216) EPFO (188) Provident Fund (160)

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