For Web Circulation Only
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)
