Employees Provident Funds Scheme, 1952
Regin. No.
Form 20
(For Office use only)

Employer’s Tel. No. : ____________
Member’s or Contact Tel. No. : ____________
Inquiry Tel. No. : 27542251
Form to be used (1) by the guardian of minor/lunatic member.
Or
(2) by a nominee of legal heir of the deceased member.
Or
(3) by the guardian of the minor/lunatic nominee of heir.
For claiming the provident Fund accumulation of minor/deceased member.
(Note : Read the instructions carefully before completing this form)
PARTICULARS OF MEMBER
1.(a) Name of the member (in Block Letters)
(b) Father’s / Husband’s Name.
(c) Name & Address of the Factory/Establishment in which the member was last employed.
(d) Account No.
(e) Date of leaving service.
(f) Reason for leaving service.
(g) Date of death of the Member (in case of Deceased member)
(h) Marital Status of the member on the day of death.
PARTICULARS OF THE CLAIMANT
2. 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)
b) Father’s / Husband’s Name
c) Sex
d) Age (as on the date of death of the member)
e) Marital status (as on the date of death of Member) i.e. Unmarried, Married, Window or Widower
f) Relationship with the deceased member
3. To be filled in by the Guardian / Manager of Minor / lunatic Member / Minor /
Nominees(s) of the Legal Heir deceased Family Member(s) member.
a) Name of the claimant (i.e. Guardian)
b) Father’s / Husband’s Name
c) Relationship with the member / deceased member
3. A. Particulars of Minor/lunatic Nominee(s) legal heir(s) Family Member(s) on
whose behalf the Provident Fund amount is claimed.
Relationship
S. No
Name
Sex
Age
Religion
Relationship with the deceased member
With guardian
1.
2.
3.
4.
Delete, if not applicable.
4.
Claimants Full Postal Address (in block letters) Shri / Smt.___________________
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 in item No. 4 above
(b) S. B. Account No. by account payee cheque sent direct for credit to my S. B. A/c. (Scheduled Bank / Co-op. Bank / P. O.) under intimation to me
Name of the Branch
Full Address of the Branch (Advance stamped Receipt furnished below)
Certificate : (1) to the best of my knowledge no posthumous child will be born to the deceased member.
(2) I Certify that the particulars given above are true to the best of my knowledge.
I certify that the minor(s) Lunatic Shri / Smt. ______________________________
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 minor member has not been employed in any Factory/Establishment to which the act applies for a continuous periods of not less than 2 months immediately preceding the date of this application.
Enclosures
Date
Signature of Left/Right/hand thumb impression of the claimant
delete, If not applicable
Contribution for the Current Financial year
Worker’s Shares
Employer’s Share
Month
Amount of wages
E.P.F.
E.P.F.(difference between 10% & 81/3% OR 12% & 81/3% as the case may be)
PENSION FUND Contribution 8.1/3%
No. of days/period of non-contributing service(if any)
1
2
3
4
5
6
April
May
June
July
Aug.
Sep.
Oct.
Nov.
Dec.
Jan.
Feb.
March
Total
Advance stamped receipt
(To furnished only in case of 5 (b) above) GJ__________
Received a sum of Rs. ____________(Rupees _______________________________ _____________________________________________) from Regional Provident Fund Commissioner / Officer in Charge of sub Regional Office _________________ Gujarat State. By deposit in my Saving Bank Account towards the settlement of Provident Fund account of Shri / Smt. ____________________________________________________________
The Space should be left blank which shall be filled in by RPFC / Office – in Charge of S.R.O
Affix Rs.1.00 Revenue Stamp
Signature or Left/Right hand thumb impression of the claimant
_____________________________________________________________________
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 has signed/thumb impressed before me
Signature of the employers or any authorized officer with Designation & Seal
(For the use of commissioner’s office)
Account settled in part / Full Entered in form 21A/24/2/6A & withdrawal Register.
Clerk S.S. (Under Rs. _____________________________
P.I.No. _______________M.O./Cheque/Account No. ____________Section _______ Passed for Payment for Rs. _______________(in word) Rs._____________________ M. O. Commission (if any) Rs. ___________________
Net amount to be paid by M. O. Date A.A.O./A.C.
(For use in Section)
Paid by Inclusion cheque No. _____________________Date ___________________ vide Cash book (bank) Account No. 3 Debit item No.__________________
S.S. A.C. R.C.
Remarks