EMPLOYEES PROVIDENT FUNDS SCHEME, 52
Form 20

Form to be used : [1] By the guardian of the minor/lunatic member
OR
[2] by nominee or legal heir of the deceased member
OR
[3] by the guardian of the minor/lunatic nominee or heir for
claiming the provident fund accumulation of minor /
deceased member
Note : Read the instructions carefully before completing this form
PARTICULARS OF THE MEMBER
1. a. Name of the member[ in Block letter] :
b Fathers / husbands name :
c Name and Address of the Factory/ :
Establishment in which the member
was last employed
d Account number :
e Date of leaving service :
f Reason for leaving service :
[IN CASE OF DECEASED MEMBER]
g Date of death of member :
h Marital status of 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. Fathers / husband's name :
c. Sex :
d. Age(as on the date of death of the member) :
e. Marital status of member [as on the day of death of :
member] (Whether married Unmarried,
widow,or widower)
f. Relationship with the deceased member :
3. To be filled in by the Guardian/Manager of the Lunatic Member/Lunatic/Minor [Nominee[s]]
Legal Heirs[s] of the deceased Member
Family Member[s]
a. Name of the Claimant { i.e. Guardian}
b. Fathers/Husband's Name
c. Relationship with the member/deceased member
3A. PARTICULARS OF THE MINOR/LUNATIC NOMINEE(S) LEGAL HEIR(S) FAMILY MEMBER(S) ON
WHOSE BEHALF THE PROVIDENT FUND AMOUNT IS CLAIMED.
S.No Name Sex Religion Relationship
with the deceased member with the
guardian
(1)
(2)
(3)
(4)
Delete, if not applicable
4 Claimant’s full postal address : Shri/Smt
………………………………………………………….
(in Block Letters) 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 No4
OR (b) By account payee cheque sent : ( ) S B Account
No………………………………………………
direct for credit to my S B Bank
……………………………………………………………
Account (Scheduled Bank /P.O) Branch
……………………………………………………………
under intimation to me (Advance Full Address of
………………………………………………….
Stamped receipt furnished below) of the Bank
………………………………………………………
CERTIFICATE:
To the best of my knowledge no posthumous child will be born to deceased member.
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 my self and the Provident Fund money claimed on behalf of minor/lunatic will be spent in his/her best interests and benefits.
I certify that the minor member has not been employed in any Factory/Establishment to which the ‘Act’ applies for a continuous period of not less than 2 months immediately preceding the date of this application.
Encl:
Date Signature or Left/Right hand
Delete, if not applicable thumb impression of the
claimant
ADVANCE STAMPED RECEIPT
(To be furnished in case of 5 (b) above)
Received a sum of Rs .................................................................................
(Rupees................................................................................................) from the Regional Provident Fund Commissioner/Officer incharge of Sub-Regional office .............................. by deposit in my savings Bank Account towards the settlement of Provident Fund, account of Shri/Smt..................................................
The space should be left blank which shall be filled in by Regional Provident Fund
Commissioner/Officer-in-charge of sub Regional Office
Signature or Left/Right hand
Thumb impression of the
claimant
Affix
Re.1.00
Revenue
Stamp