CHECK LIST FOR DEATH CLAIM 20 / 5IF / 10D or 10C MIS-3

VD/BRD/ UAN : .
Name of PF Member
[MARRIED / UN-MARRIED ]:

Date of BIRTH Date of JOINING Dt of EXIT / 58 Age Date of DEATH

Following documents to be submitted/Enclosed for

BY CLAIMANT :
1. Original Death Certificate
2. L.S.M.
3. Form: 05 / 10.
4. Descriptive roll of all family members with 3 passport photo affixed.
5. Age Proof Of All Family Member [Birth Certificate/S.L.C./Passport] .
6. Aadhar card of deceased member and family member.
7. Bank Account Of All Family Member (in the same Bank Branch with SAME IFSC CODE)
(If Child Is Minor Than A/c under natural guardian) [Only SBI, BOB, ICICI & HDFC for VADODARA Region]
8. Ration Card or Pedhi Nama :
9. PF Status of the prior service and any service between date of exit and date of death. Unemployment certi.

BY EMPLOYER:
1. No Break Certificate
2. Death while in sercive certificate.
3. Last 03-Month Muster-Roll/Wage-Sheet.
4. DSC Letter Print
5. e-Nomination Print/ Letter for No e-Nomination.
6. EXIT Date & Reason updated in system / Joint Declaration.
7. Date of JOIN & EXIT- Date of Death break period/month Contribution/NCP data.
8. All the documents/copy enclosed with CLAIM FORM must attest by the establishment/authorized signatory.
If CLAIMANT is illiterate then THUMB IMPRESSSION must attest by the establishment/authorized signatory .
9. Other documents according to Case status (optional): Original Scheme Certificate/Indemnity-Bond;
Guardianship Certificate/Succession Certificate, Divorce Order(By Court).**** LATE CLAIM FILING
REASON/CLARIFICATION.

For EPFO Office Use only.

If agreed to we may send the claim THROUGH DAK to concern A/c Task for further verification.
DATE:
 www.e
कर्मचारी भविष्म िधि संगठध pfindia.
www.epfindia.gov.in
gov..in
EMPLOYEES’ PROVIDENT FUND ORGANISATION मोबाइल न.
र्त्ृ मE र्ार् म र्क कप ो जिट द वािा रपत र Mobile No.
Composite Claim Form in Death Cases Mobile
रपत र -20 (भविष्म िधि भEगताध)/ रपत र 10-डी ( क शध)/रपत र -5आईएफ (ईडीए आई) Number
[Form-20 (PF Payment)/Form-10-D (Pension)/ Form - 5 IF (EDLI)]
(जो लागू हो, उस पर निशाि लगाएं) (i) भविष्a निि / (ii) पें शि/ Pension ( ) (iii) बीमा (ईडीएलआई)
1
Tick whichever is/are applicable Provident Fund ( ) पें शि दािा का प्रकार/Type of Pension claim: Insurance EDLI] ( )
मत
ृ क सदस्a का िाम (बड़े शबदों में ):
2
Name of the deceased member (in CAPITAL letters)
2a सदस्य क� जन्म ितिथ / Date of Birth of Member
3 (a) वपता का िाम / Father’s Name :(b) पनत/पत्िी का िाम/ Spouse’s Name :
मत
ृ क सदस्a क िविािहक ्स्तनत /
4
Marital status of deceased member
a) मत
ृ क सदस्a का आ ार िंबर (aिद उपलब हो)
Aadhar Number of the deceased member (if available)
5 b) aू.ए.एि. / Universal Account Number (UAN)
c) भविष्a निि खाता संख्aा (aिद a.ू ए.एि. उपलब िह ं हव ) / PF Account
Number (in case UAN not available)
6 Date of Joining and Date of Leaving the Fund. DOJ DOL
a)Whether Scheme Certificate has been issued (Yes/No)
क्aा स्क म प्रमाणपत्र जार ककaा गaा हव (हां/िह ं)
b)If Yes, Number of Scheme Certificate
7
aिद हां, स्क म प्रमाणपत्र क संख्aा
c)Scheme Certificate issuing office
स्क म प्रमाणपत्र जार करि़े िाल़े काaाालa का िाम ि पता
गवर अंशदाaी स़ेिा क अिि (िर्ा/माह/िदि) / Period of Non-Contributory
8
service (Year/Month/Days) – (To be filled by the employer)
9 सदस्a क मत्ृ aव क नतित/ Date of death of the member
क्aा सदस्a क मत्ृ aव स़ेिाकाल क़े दाराि हवई ती (हां/िह )ं /
10
Whether the member had died while in service(Yes / No)

दािाकताा अव्aस्क /िाममनत /कािूिी उत्तराि कार / ितामाि पररिार क़े सदस्a का वििरण ्जिक़े द्िारा दािा प्रस्तवत ककaा गaा हव /
भविष्म िधि क शध तथा बीर्ा (ईडीए आई) हमतE वािाकताम का वििरण / CLAIMANT’S DETAILS FOR PROVIDENT FUND, PENSION AND INSURANCE (EDLI)
*Particulars of the claimant/minor/nominee(s)/legal heir(s)/surviving family member on whose behalf the claim is submitted
िविािहक संबं Relationship with
वपता/Father’s / जन्म नतित
क्र.सं. आ ार िंबर/ मलंग ्स्तनत सदस्a क़े
िाम/ Name पनत-पत्िी का िाम/ Date of अमभभािक
S.N. Aadhar Number Gender Marital सात
Spouse’s Name Birth Guardian
11 Member Status
i
ii
iii
iv
v
* In case of more than five family members, the details of family members may be furnished in a separate sheet, duly attested by the employer.

भविष्म िधि तथा ईडीए आई (बीर्ा) कम भग

E ताध हमतE बैंक खातम का वििरण Bank Account details for payment of PF & EDLI:
भवगताि ह़े तव बैंक खात़े का वििरण Claimant – I Claimant –II Claimant –III Cla
Bank Account details for payment दािाकताा – I दािाकताा – II दािाकताा – III दाि
िाम Name

बचत बैंक खाता संख्aा

12
Saving Bank Account No.
बैंक का िाम ि पता
Name & address of the Bank
आई एफ एस कोड
IFS Code of Bank
क शध हमतE बैंक खाता वििरण / BANK ACCOUNT DETAILS FOR PENSION
भग
व ताि ह़े तव बैंक खात़े का वििरण Claimant – I Claimant –II Claimant –III Claimant – IV
Bank Account details for दािाकताा – I दािाकताा – II दािाकताा – III दािाकताा - IV
payment
िाम Name

13 बचत बैंक खाता संख्aा

Saving Bank Account No.
बैंक का िाम ि पता
Name & address of the Bank
आई एफ एस कोड
IFS Code of Bank
दािाकताा का पत्र व्aिहार का पता
14 Full Postal address of claimant
वपि/ Pin..............................

- aह प्रमाणणत ककaा जाता हव कक उपaक्

वा त वििरण म़ेर जािकार क़े अिस
व ार सह हव
- Certified that the particulars are true to the best of my knowledge.
दािाकताा का हस्ताक्षर
Claimant’s signature निaोक्ता का हस्ताक्षर
Employer’s Signature
िाम Name: …………………… निaोक्ता का पदिाम तता मह
व र
Designation & Seal of Employer
संलग्िक/Enclosures i) मत्ृ aव प्रमाणपत्र/ Death Certificate
Enclosures: ii) सभी दािाकतााओं का संaक्
व त फोो ो / Joint photograph of all the claimants
iii) दािा करि़े िाल़े बचचों क़े जन्म का प्रमाणपत्र / Date of Birth certificate of children claiming pension
iv) aोजिा प्रमाणपत्र (aिद लागू हो) Scheme Certificate (if applicable)
v) बैंक खात़े क़े सत्aापि ह़ेतव एक रद्द चवक /पासबक
व क़े पहल़े प़ेज क अमभप्रमाणणत प्रनतमलवप/ For verification of bank accounts,
a copy of cancelled cheque or attested copy of first page of bank Pass Book.
 LIST OF SURVIVING MEMBERS
CERTIFICATE

This is to certify that ________________________________________ an employee of

______________________________________________________ and member of Employee’s
Provident Fund ‘1952 and Employees’ Pension Scheme 1995 bearing Member ID
______________________died on __________________
He has Left behind him the following person(s) being the members of his family.
SLNo Name Gender Date of Marital Relationship with
Birth/Age Status deceased member
1

1. It is also certified that the above is the exhaustive list to the member of the family of the
deceased and that none is left out.
2. For the purpose of the certificate “Family” means “Family” as defined in Para 2(g) of the
Employees Provident Fund Scheme’1952.

___________________
Signature of Authorised
Person of the Establishment
 vtrr / ronnn-s
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[tu mw zo (+)]
THE EMPLOYEES'PROVIDENT FI]NDS SCHEME, 1952,
IParagraph j6(2)(a)]
AND TYHE EMPLOYEE'S PENSION SCHEME,1995
IParagraph 20 (4)l
qrd lo * ttn q-rd ers tFdqrt qGq ftfu, o4q,6 6'* frft eil zFdaT€i e-te's'eT 4qT fffu
frvfiqHT6lcIEdu*"6*frffi
Return of Employees qualifying tbrmembership of
the Employees' Provident Fund, Employees Pension Fund &
the

-
Employees' Deposit Linked Insurance Fund for first time during
the month of ........................20.
the

{fl cqr a (o6,q qfrq ffi wl o4ulq f-qn I}ft') S r+ru sngm o} t-qr qrv r

(To be sent to the Commissioner with Form 2 @PF & EPS)

h+et/+enqiT zFI qlq qd rldr/Name & Address of the Factory/ Estt.

fr. dsr odqtt atr ilq ftmoraqqr sqfrftl ftrI ftlt or ftfu or ssrq e-{i fi siFrgfti
tt. (we 3rert {) (ffifl+qrrd Date of Sex scw E-+i ftFrvr Mt-ofrg;-a Remarks
Sr. Account Name of the C qft al clq) biflh ffFIFI qsB (6q c{olqr
Date of qi"m of q'A dtxd)
No. No. member Fathcr's Name Joining
(in block letters) (or husband's Name in the Fund Totd period ofprevious
case of married woman) sen'icc a son the datc of
joining the Fund (En'
closc Scheme cenif icare
ifapplicable)

I 2 3 4 5 6 7 8 9

ftqiq/oate: ffii6r qr or;q crE-f-d 3rffi * twran

Signature of the Employer or other
authorised offi cer of the Factory/Establishment

Qrret/tQrmt 6I *6t/st rnp of the factory/ Esu

 Er4qffi qfrq ftfu
srt![
rssz [i-n rrm ao (z) (a)
sffq,
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(q)] dt
eft o4q6 f-qn dq', rsss [ttr flu, zo (z)]
TIIE EMPLOYEES' PROVIDENT FUNDS SCIIEME' 1952, 7 ra ra sraph 3 6(2 )( a ) & ( b )l
EMPLOYEE'S PENSION SCHEME, 1945 tParasraph 20 (2)l
qrt b StiT{ ffi BH sT-d sflrit fr ffi qrd............... zo / R.rurn of the members leaving service
durina the month of ..................... 20
{s qrd r (ofarfr qfrq ftfu G o'd"rt i'fi f4fr) & eru cr"gm o} tq qrc t

(To be sent to the Commissioner with Form 2 (EPF & EPS)

*-+2ff/wfrr* or ilq G rl.dl/ I,lame & Address of the Factory/Estt............
ots{em/cooeNo.......
fr. dsr {i. s(er 6r iFI ftar or rq qr ffiffia cH Bilgi ff 6rist siWs
{i. Account No. (we srert C) (ffi'drlqrre fdftr Reacons for Remarks
Sr. Name of the d vfr or <n) Datc of leaving Service
No. member leaving Scrvice
Father's Name
(in block letters) (or lrusband's Name in
case of married woman)
., ,7
I 3 4 5 6

fiqio/oate: i+d6r qr srq sIfrFa sffi *' rsrrm

Signature of the Employer or other authorised officer

ffi/*QirqqT ff frElsturnp ot the factory Estt.

* EqqrTdrqfu{I<-{q (o)drbfu iq (e) (6)ur (u)}rgwr$qrft'fi.E\r6rt (s)fristiiserdsq
t it+ + faq ma A-.g_* (, I E-c.{ (q ) ffi
it +c b 6nET ryf enr+nr (s) {{€TK ( a).tot { runm ( o)
srq'rQlrqqtffin-* lFu}+rtnr#aenqdorqdsot) (q) f.g (s') rc a{ffcrgdiw t

India for
whcther the member is (a) retiring according to para 69( I ) (a) or (b) of the Scheme.(b) lealing
,i please state
(e)
p"r-*"ri."ttt"."nt uUroad (c) reterenchemei'r (d) Pt. &-total disablementtlue tgemployment injury discharged
(The name & address of the Employers
[g ,eSgning f.om or leavi'g iervice (g) talking up employment elsewhere
should be stated) (h) death (i) attained the age of 58 years'
ild'1fu'd;#"i:d'li:.-;.:'.--::..-:.:::.-"iur6ls-dsr.{sI"""'tnftnrrqrt,6}sa}ft6
trql "
ft{rq oft ftqq, uo t srfl fd....'.........'...... Fc} 61 6ffi 3o1ro-w er(t ft Fqt
qg t

"Certified that the member mentioned at Se al No. ...'..........'.."." Shri

was paid/not paid reternchment compensation of Rs..'..'.. ." " "" ........ under

theIndustrial Dispute Act, l9'{7 "

ffio,r t (.Ffitst/signature of the Employer