No. I
Details of Income:(1)Administration Charges.
No. II
Receipt from Government and other Accounts:(1)From Government for Administration of Family Pension Scheme A.E. (C.D.) Scheme.(2)From other Accounts.Total:Details of Receipt from other Accounts appearing in Sch. No. II(1)From administration A/c of E.D.L.I. Scheme.(2)From other Accounts.Total:Less:Amount transferred to other Accounts in Adjustment.Transfer from A/c. No. 2 to Account No. 4 and vice versa as per Regional Offices Accounts and Central Office Accounts.Total:Net Total:
No. III
Employees' Provident Fund A/c:Balance as per last Balance Sheet.Add:Contribution (including refund of withdrawal and transferred securities) received during the year.Contribution received by way of transferred securities (H.Q. Office contra).Interest credited to member's Account.Other Receipts.Total:Less:Payment made during the year to outgoing members on final settlement.Premia paid during the year on member's Life Insurance Policies.Loan paid during the year to the members.Unclaimed Deposit Account.Miscellaneous Payment Amount of securities transferred back to exempted estts.Total:Balance as on 31-3-20........
No. IV
Unclaimed Deposit Account:Balance as per last Balance Sheet.Add:Amount transferred during the year.Less:Amount paid during the year.Balance as on 31-3-20 ........
No. V
Special Reserve Fund:Balance as per last Balance SheetAdd:Amount recovered from employers Interest on S.R.F. Account.Less:(1)Amount paid from Special Reserve Fund during the year.(2)Amount transferred to Death Relief Fund.Balance as on 31-3-20........
No. VI
Death Relief Fund:Balance as per last Balance Sheet.Amount received from S.R.F. Account.Amount recouped during the year.Total:Less:Payment made during the year.Balance as on 31-3-20.........
No. VII
Interest Suspense Account:Balance as per last Balance Sheet.Less:1. Interest credited to members Account during the year.
2. Interest paid on deposits refunded to exempted estts.
3. Interest paid to vendors.
4. Interest accrued on S.R.F. A/c. adjusted.
5. Interest accrued on fluctuation Account adjusted.
6. Balance in the Accounts to be credited to the subscribers/members A/c upto 31-3-20...........
Add:1. Interest realised on investment of securities.
2. Interest on S.B. Accounts (Central).
3. Interest on S.B. Accounts (Regional).
4. Interest on securities received from the estts.
5. Interest realised from members on loans.
6. Penal damages on belated contributions received during the year.
7. Amount of loss on sale of securities credited.
Balance as on 1-4-20........
No. VIII
A.Staff Provident Fund A/c:Balance as per last Balance Sheet.Add:Contribution (including refund of withdrawal) received during the year.Interest credited to member's Account.Other Receipts.Less:Payment made during the year to outgoing members on final settlement.Premia paid during the year on member's Life Insurance Policies.Loan paid during the year to the members other payments (Transfer to other Regions).Balance as on 31-3-20........B.S.P.F. A/c transferred from other Regions:Balance as on 31-3-20........Add:Amount transferred out to the regions.Less:Amount received from other regions.Balance as on 31-3-20........Total (A+B):
No. IX
Staff Provident Fund:Interest Account.Balance as per last Balance Sheet.Add:(1)Interest realised on investment of securities.(2)Interest on S.B. Account.Less:(1)Interest credited to member's Account during the year.(2)Interest paid to vendors.Balance as on 31-3-20....
No. X
Pension-cum-Gratuity Account:Balance as per last Balance Sleet.Add:Amount transferred during the year from A/c. No. 4.Interest realised on S.B. Account.Interest realised on securities during the year.Less:Payment made by the regions.Interest paid to vendors during the year.Balance as on 31-3-20....
No. XI
Investment fluctuation A/c:(A)Gain on redemption of securities accounted up to.(B)Gain on redemption of securities accounted for the year.(C)Interest on Fluctuation Account.Total:Less:Loss on sale of securities.Balance as on 31-3-20........
No. XII
Building Construction Fund:Balance as per last Balance Sheet.Add:1. Provision made during the year.
2. Interest credited to the fund.
Balance as on 31-3-20........Note.-The cost of Land and Building acquired as on 31-3-20........ is Rs. .................... and the amount available for construction purposes as on 31-3-20........ is Rs .....................
No. XIII
Building Maintenance (Repair, Renewal, Replacement):Fund:Balance as per last Balance Sheet.Add:(1)Amount appropriated from Revenue Surplus during the year.(2)Interest credited.Balance as on 31-3-20........
No. XIV
Revenue Surplus:Balance as per last Balance Sheet.Less:(1)Amount adjusted by the Regional Office.(2)Excess of expenditure over income during the year as transferred from Income and Expenditure Appropriation Account.Add:(i)Amount adjusted by Regional Offices.(ii)Excess of income over expenditure during the year as transferred from Income and Expenditure Appropriation Account.Balance as on 31-3-20........
No. XV
Sundry Credits :-(a)Suspense Account (Unclassified)(f)Amount repayable to E.D.L.I. Account.(g)(i)Pension Fund Investment A/c. and S.P.F. Investment A/c.(ii)Amount invested in E.P.F. A/c.(h)Erroneous Credit to A/c. No. 5(i)Amount not accounted for by the Regions though received in A/c. No. 5 from A/c. No.1.(ii)Extra credit given by Bank to A/c. No. 1/3 without any correspondingdebit to A/c.(iii)Amount credited to A/c. No. 5, No. 1/3 but not debited to A/c. No. 5(iv)Erroneous credit to A/c. No. 5(i)Erroneous/Excess credit to A/c. No. 8(j)Excess credit to A/c. No. 9.
No. XVI
Investment Account of Employees' Provident Fund:(a)Securities purchased centrally (cost price).Balance as per last Balance Sheet.Add:(i)Amount invested centrally during the year (cost price)(ii)Gain on the purchase of securities for the years.Less:(i)Loss on sale of securities during the year.(ii)Value of securities redeemed during the year.Balance (a) as on 31-3-20........(b)Securities transferred by regions: balance as per last Balance Sheet (Accepted value).Add:Securities received during the year (Accepted value).Other Adjustment.Less:Securities returned back to estts. (Accepted value).Other Adjustment.Balance (b) as on 31-3-20........Total (a) and (b).
No. XVII
Investment Account of Staff Provident Fund:Balance as per last Balance Sheet.Add:Amount invested centrally during the year (Purchase price).Total:Value of securities redeemed during the year.Less :
No. XVIII
Investment Account of Pension-cum-Gratuity Fund (Staff):Balance as per last Balance Sheet.Add:Amount invested centrally during the year purchase price.Less:Value of Securities redeemed during the year.Balance as on 31-3-20........
No. XIX
Investment A/c of Administration Fund:Balance as per last Balance Sheet.Add:Investments made.Less:Securities redeemed during the year.Balance as on 31-3-20........
No. XX
Recoverable advance (staff):as on 31-3-20........(b)House building advance.(d)Warm clothing advance.(f)Natural calamity advance.(i)Advance to Staff Co-operative Canteen/Stores.(j)Miscellaneous Payment.Total:
No. XXI
Amount in transit:(d)Pension-cum-Gratuity Account No. 9(f)Pension-cum-Gratuity Investment Account.Total:
No. XXII
Cash balance as on 31st March:E.P.F. Account No.1E.P.E. Account No. 2E.P.F. Account No. 4E.P.F. Account No. 5E.P.F. Account No. 8E.P.F. Account No. 9E.P.F. Investment A/cS.P.F. Investment A/cPension-cum-GratuityInvestment Account.TOTAL: (a) + (b)
No. XXIII
Sundry debits:(A)Suspense Account (unclassified)(D)Erroneous debit to A/c No. 5(a)Excess accounted for by Regional Office as transfer to A/c No.'5 from Account No. I(b)Extra debit made to A/c. No. 5 by Bank.Total:|}FORM 12 (Revised)THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952[See paragraph 38(2)]Statement of contributions for the month of ...........................Wage Period From ...........................................................To..........................................................Name and Address of the Establishment ........................................Code No...........................
| Sl. No |
A/c. No. |
Name of the member (in block capitals) |
Wages retaining allowance (if any) and D.A. including cash value of food concession paid to the member during the wage period |
Amount of member's contribution deducted from the wages |
Employer's contribution |
Remarks |
| EPF |
FPF @ 11/6% |
Total |
EPF |
FPF @ 11/6% |
Total |
| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
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| Total No. of subscribers |
Wages on which contributions are recovered |
Amount of contributions due as per recoveries made in the wages/acquittance register |
| Worker's share |
Employer's share |
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E.P.F.(a)
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E.P.F. @ 11/6%(b)
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Total(c)
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E.P.F.(a)
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E.P.F. @ 11/6%(b)
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Total(c)
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| 1 |
2 |
3 |
4 |
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Worker's share |
Employer's share |
Total |
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EPF(a)
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FPF 11/6%(b)
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Total(c)
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EPF(a)
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FPF 11/6%(b)
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Total(c)
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| 5 |
6 |
7 |
8 |
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1. Total amount remitted in Account No. I Rs ..............................................
Date of remittance ..................................................................................2. Total amount remitted in Account No. 10 Rs ............................................
Date of remittance ..................................................................................
| Amount of Adm. Charges due 0.37% of the amount of wages shown in column 2 |
Amount of Admn.Charges remitted in A/c No. 2
|
Date of remittance |
Name and location of the Bank in which remitted or No. and date of the cheque/draft sent to Regional Officer |
Whether the triplicate challan receipt is enclosed, if not, state reason |
Remarks |
| 9 |
10 |
11 |
12 |
13 |
14 |
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| To, |
To, |
| The Commissioner, |
M/s_____________________________________________________ |
|
Employees'Provident Fund
|
________________________________________________________ |
| ________________________ |
________________________________________________________ |
| 1. Name |
________________________________________________ |
| 2. Fathers/husband's name in case of married woman |
________________________________________________ |
| 3. Name and address of previous employer |
________________________________________________ |
| 4. EPF account number with previous employer |
________________________________________________ |
| 5. By whom the PF account of the previous establishment is kept |
Regional PF Name of the Commissioner at P.F. Trust |
| 6. EPF account number with the previous employer (if allotted a separate one) |
________________________________________________ |
| 7. Date of leaving service with previous employer |
________________________________________________ |
| 8. Date of joining the present employer |
________________________________________________ |
| |
|
| Date_____________________ |
Signature/left hand thumb-impression of the member |
| TO BE FILLED IN BY THE PRESENT EMPLOYER |
| 9.Name and address of the establishment |
________________________________________________ |
| 10. EPF Code Account No. allotted to the member |
________________________________________________ |
|
11. EPF Account No.allotted to the member separately, if any
|
________________________________________________ |
| 12. By whom the EPF account of the member in the present establishment is kept: |
(i) By Regional Office at_____________________________ |
| Being an unexempted establishment |
(ii) Sub-Regional Office at____________________________ |
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(iii) By exempted PF Trust, viz._______________________ |
| Being an unexempted establishment |
________________________________________________ |
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(iv) By Private PF-Not covered under Act, viz ___________ |
| 13.By whom the EPF account of the member in present establishment is kept: |
(i) PF-Regional Office at_____________________________ |
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(ii) PF-Sub-Regional Office at_________________________ |
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________________________________________________ |
| |
________________________________________________ |
| 14.In whose favour transfer is to be effected, i.e., payee's details |
________________________________________________ |
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| Date__________________________ |
Signature of Employer/AuthorisedOfficial with Office Seal |
| P.I. No. |
CLERK |
HC |
AAO |
AO/APFC |
| Scroll No. |
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| Paid by Cheque No. _____________________________________________________________Dated____________________________ |
| Cashier/Clerk |
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Head/Clerk |
|
A.P.F.C. |
1. Name ..........................................................................................................................................
2. Father's name (or husband's name in case of married woman) ..........................................
3. Name and address of previous employer, whether
Unexempted/ Exempted/uncovered .....................................................................................4. (a) Previous Provident Fund Account No .............................................................................
(b)Previous Family Pension Fund Account No ...................................................................5. Date of leaving service with previous employer ..................................................................
6. Name and address of the employer .......................................................................................
7. Whether Unexempted/ Exempted/uncovered .....................................................................
8. (a) Present Provident Fund Account No ...............................................................................
(b)Present Family Pension Fund Account No. (if any) ........................................................9. Date of joining with present employer ....................................................................................
Signature or left/right hand thumb-impression of the memberEndorsement to be completed by the forwarding authorityForwarded with the particulars furnished above duly verified. **(The rules of our private provident fund permit such transfer and hence the transfer may be made. The cheque may be drawn in favour of ...........................including/excluding bank collection charges.)Signature of Employer or other Authorised Officerof the factory/ establishment with official seal* Left hand thumb-impression in the case of illiterate male member and right hand thumb-impression in the case of illiterate female member.** Will apply in case of transfer to uncovered establishment.Note.-In case of transfer to provident fund accumulation to uncovered establishment, the benefit under Family Pension Fund Scheme should be paid to the member.FORM 14THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952(See paragraph 62)Application for financing a life insurance policy out of the provident funds accountTo,The Commissioner,Employees' Provident FundI ............................. 5/o/D/o/W/o............................. (Name in block capitals) an employee of ....................authorise the Commissioner to--(i)withdraw, a sum of Rs ............................(Rupees..............) from my Provident Fund Account No .................and remit the same to the Life Insurance Corporation of India towards the initial premium in respect of my Life Insurance Policy/proposal for Life Insurance details of which are given herein;(ii)make periodical withdrawal of Rs ................(Rupees................) from my Provident Fund Account No ........................each time the premium falls due for payment and remit the same to the Life Insurance Corporation of India towards the premia in respect of my Life Insurance Policy, details of which are given herein so as to reach the said Corporation within the time allowed for such payments;(iii)to convert the said insurance policy into a paid-up one when the credit in my provident fund relating to my own contribution becomes inadequate for the payment of any premium, unless the payment of further premium is arranged by me with the Life Insurance Corporation of India and I inform the Regional Commissioner accordingly;(iv)to pay late fees and/ or interest on my own contribution in my Provident Fund Account if any premium cannot be remitted to the said corporation in time because of delay in sending to the Commissioner the policy duly assigned to the Central Board of Trustees of the Employees' Provident Fund or any other reason for which I or my employer may be responsible.2. I accept that :
(i)the authorisation at paragraph 1(ii) above shall be effective only when my life insurance policy duly assigned to the Central Board of Trustees, Employees' Provident Fund has been received by the Commissioner after proper registration of the assignment in the books of the said Corporation,(ii)the said authorisation shall thereafter remain operative till such time as I continue to be a member of the Fund and have enough accumulations to my credit as my own share in the Fund or till the maturity of the policy, whichever is earlier,(iii)the terms of the policy shall not be altered nor shall the policy be exchanged for another policy without the prior written consent of the Regional Commissioner.3. The policy is enclosed for inspection/will be forwarded when received/has already been assigned to the Central Board of Trustees of the Employees' Provident Fund and accepted by the Commissioner vide his letter No ...................... dated the....................
4. I am aware that the policy is to be assigned to the Central Board of Trustees of the Employees' Provident Fund as security within six months of the date of the first remittance by the Fund to the said Corporation and sent to the Commissioner after registration of the assignment in the books of the said Corporation.
5. I declare that :-
(a)I have been a member of the Fund for the period of not less than two years which is the minimum period for being eligible for financing insurance policy from the Fund.(b)The amount standing to my credit in my E.P.F. Account (my own share) is Rs ................as on...............which is sufficient for making payment to L.I.C. for two years.(c)My annual contribution to the fund of Rs ................which is sufficient to pay my yearly premia.(d)I propose to nominate the same person as for the P.F.6. I also declare that the policy is free from any "encumbrances" and the details of the policy/proposal given herein are correct to the best of my knowledge.
7. Details of the *policy/proposal :-
(i)Address of the branch office or unit of the Life Insurance Corporation where the policy account* is to be maintained.(ii)*Policy/proposal No. and date.(iii)Sum assured/proposal to be assured.(iv)Probable date of purchase of the policy.(v)Whether the proposal has been accepted and if so, by what date the first premium is to be paid.(vi)Cost of the policy (in the case of single payment of policy).(vii)Amount of yearly premia.(viii)Due date(s) for payment of premium.(ix)Date of payment of last premium.(x)Whether age has been admitted. If not, state the nature of proof presented to Life Insurance Corporation.(xi)Name(s) of the nominee(s) under section 39 of the Insurance Act, 1938.(xii)Guardian appointed under section 39 of the Insurance Act, 1938 in respect of minor nominees, if any.(xiii)Details of any previous policy already assigned to the C.B.T., or "Certified that I have not withdrawn any amount previously for financing out of my provident fund account."(xiv)Remarks.Date ......................................**Signature or left/right thumb-impression of the memberCertified that this form has been *signed/thumb-impressed before me by ................(Name of member) Account No.........................employed in .......................(Name of establishment)Signature of the employer or his authorised officialDesignation ......................Code No. of the Estt. .....................Name and address of the establishment and its stampDate ...................................* Delete portion not applicable.** Left hand thumb-impression in the case of illiterate male member and right hand thumb-impression by illiterate female member.For use in Regional Commissioner's Office(Accounts Section)Please furnish the following information in respect of the subscriber :
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Average of yearly contribution(employee's share only) on the basis of recent 12 months Form No. 12
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Total contribution (Employee's share only) as on |
Whether any other L.I.P. advance has been granted before. If so, mention the date of withdrawal |
Whether the subscriber has Contributed for two years |
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| Clerk |
Head Clerk |
Accounts Officer |
R.P.F.C. |
| (Insurance Section) |
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D.P.Sheet prepared and put up for signature
|
| Clerk (Ins.) |
H.C. (Ins.) |
Accounts Officer |
R.P.F.C. |
2. The said Policy is enclosed. Please have the assignment registered in books and return the Policy to the Regional Provident Fund Commissioner .................................................State.
(give complete address)Yours faithfully,Signature of the AssigneeFull AddressFORM 16THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952Application for advance from the Fund under paragraph 68-BPart I
(To be completed by the member)(1)Name of the member (in block letters) ...................................................................................(2)Father's name (or husband's name in the case of married woman) ...................................(3)Name of the factory/ establishment ......................................................................................(4)Account No ...............................................................................................................................(5)Rate of monthly basic wages and dearness allowance .........................................................(6)Amount of advance required ..................................................................................................(7)Purpose for which advance is required:(a)Purchasing a dwelling-house.(b)Purchasing a dwelling site.(c)Construction of a dwelling-house.(d)Addition/substantial alteration or substantial improvements necessary to the dwelling-house owned by member.(e)Completing the construction of the dwelling-house already commenced by member.(f)Acquiring a flat in a building.(8)Whether any advance has been sanctioned for any of the purposes mentioned against Serial No. 7. If so, the date of sanction thereof ................................(9)Area and location of the dwelling site/house intended to be purchased/constructed/already purchased/constructed. Whether the site purchased/intended to be purchased/constructed is within or outside municipal area ..................(10)Name and address of the present owner of the dwelling site/house intended to be purchased .....................................(11)Present state of the dwelling-house or the stage at which the construction is now on [to be filled in if the advance is required for purpose (d) or (e) mentioned against Serial No. 7......](12)Desired mode of remittance and the address to which remittance is desired :(a)By postal money order at member's cost.(b)By crossed cheque through post. (Please send advance receipt in the enclosed form).(13)List of Documents to be enclosed in case of 7(a) and 7(b)-(i)Title Deed of proposed seller.(ii)Non-encumbrance certificate in respect of the dwelling site/house to be purchased.(iii)Agreement with the vendor for the purchase of site/house.(iv)An estimate of the cost of construction in the case of the advance for the construction of the house.7.
(c)and 7(d)(i)Original title deed for certificate from appropriate revenue authority regarding ownership and non-encumbrance of the land.(ii)Sanctioned construction plan.Delete items if not applicable.Conditions(14)I undertake to comply with the following conditions:(i)The amount of advance shall be utilised for the purpose applied for.(ii)If the amount of advance is in excess of the actual expenditure incurred for the purpose for which the advance was granted the excess shall be refunded to the Fund within 30 days of the finalisation of the purchase or completion of the construction or completion of the additions to the dwelling-house as the case may be.(iii)If the advance is for construction of dwelling-house, the construction shall be commenced within six months of the withdrawal of the first instalment and completed within six months of the final instalment.(iv)If the advance is for the purchase of a dwelling site or house, the purchase shall be completed within six months of the withdrawal.(v)The amount of the advance shall not be utilised for constructing a dwelling-house on land which is not owned solely by me.(vi)The amount of advance shall not be utilised in purchasing a dwelling site or house which is not free from encumbrances and which is a share in a joint property.(vii)Such title deeds, plans, other documents and information related to the intended purchase, construction or addition as may be called for by Commissioner from time to time shall be furnished to him on demand.(viii)A declaration in the form prescribed by the Commissioner shall be furnished to him immediately on finalisation of the purchase or completion of the construction or addition to the house.(ix)If the purchase or construction for which the advance is granted does not materialise or if there is any breach of the conditions specified herein or in the EPF Scheme the entire amount of the advance together with interest thereon at the rate of 6-1/4% per annum shall be refunded to the Fund.DECLARATION(15)I declare that--(i)I have not taken any advance from the Fund under Paragraph 68-C of the EPF Scheme.(ii)The dwelling site/house intended to be purchased out of the advance applied for is free from encumbrances and is not a share in joint property.(iii)Without the further advance now applied for the construction already commenced cannot be completed/the additions which are essential cannot be made.(iv)I am the sole owner of the land on which I intend to construct a dwelling-house out of the advance applied for.(v)I have not taken any advance from the Fund under Paragraph 68-B/68-B(5).*(vi)All requirements of the local authorities in connection with the intended construction/purchase have been satisfied.Date .................................**Signature or left/right hand thumb-impression of the memberPostal address:*Delete terms if not applicable**Left hand thumb-impression in the case of illiterate male member and right hand thumb-impression in the case of illiterate female member.Part II
(To be filled in by the employer)Certified that the application has been signed by .........................employed in my factory/ establishment after *he/ she has read the contents/the contents have been explained to him/her by me and that the Account No. and the rate of monthly basic wages given in the application are correct. Following documents furnished by him are enclosed herewith:(ii)Non-encumbrance certificate in respect of the dwelling site/house to be purchased, duly signed with official seal from appropriate revenue authorities.(iii)Extract of Property Register/VII/XII duly signed with official seal by appropriate revenue authority.(iv)Agreement with the vendor for the purchase of the site/house.(v)Sanctioned construction plan and an estimate of the cost of construction in the case of the advance for construction of the house.(Vi)Non-agriculture use certificate from appropriate revenue authority (in respect of agricultural land) on which dwelling-house is proposed to be constructed.(vii)Bank advance receipt duly signed by the applicant.Date ..........................Signature of the employer or an authorised official of the factory/ establishmentRegd. No. of the factory/ establishmentDesignation of the signing official with stamp of the factory/ establishmentCode No. of the factory/ establishmentDelete items if not applicable.**Left hand thumb-impression in the case of illiterate male member and right hand thumb-impression by illiterate female member.
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Payment authorisedNo.........................AuditorH.C.A.O.
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Part III
(For use in Regional Commissioner's Office)(a)Years of service put in by the member ...............................(b)Total of accumulations standing to the credit of the member as his own share of contribution ..............................as on....................................(c)Whether in case of construction of house any proof to show that the land belongs to the member of his/her spouse has been submitted ......................................(i)Original title deed.(ii)Non-encumbrance certificate from appropriate revenue authority.(d)Whether in case of purchase of dwelling site/house title deed of the proposed seller has been produced along with an agreement-with the vendor for the purchase of site/house as the case maybe.(e)Recommendations by the clerk with his dated initials.(f)Recommendations by the H.C. with his dated initials.(g)Recommendations by the Accounts Officer.(h)Orders of the Regional Commissioner.FORMS 17 & 18[Not printed]FORM 19THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952[Paragraph 72(5)]Application by an Adult Member of the Employees' Provident Funds Scheme, 1952 for claiming the Employees' Provident Fund Dues
| 1. Name of the member (in block letters) |
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_______________________________________________________ |
| 2. Father's name (or husband's name in the case of married woman) |
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_______________________________________________________ |
| 3. Name and address of the factory/ establishment in which the member was last employed |
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_______________________________________________________ |
| 4. Account No |
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_______________________________________________________ |
| 5. Date of leaving service |
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_______________________________________________________ |
| 6. Reason for leaving service |
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_______________________________________________________ |
| 7. Full postal address (in block letters) |
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Shri/Smt./KumariS/o/W/o/D/o_____________________________ |
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Pin____________________________________________________ |
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8. Mode of remittance [Put a"tick" (√) in the box against the one opted]
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| (a) by postal money order at my cost |
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To the address given against item No. 7 |
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| (b) by account payee cheque sent direct to credit tomy SB A/c (Scheduled Bank/P.O.) under intimation to me |
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SB A/c (No in figures)_____________________________________ |
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(in words)______________________________________________ |
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Name of the Bank _______________________________________ |
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Branch________________________________________________ |
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Full address____________________________________________ |
| Month |
Wages |
Contribution |
Period of break, if any |
Month |
Wages |
Contribution |
Period of break, if any |
| Employee |
Employer |
Total |
Employee |
Employers |
Total |
| EPF |
FP |
EPF |
FP |
EPF |
FP |
EPF |
FP |
EPF |
FP |
EPF |
FP |
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| Signature of the employer or authorised official |
Signature or left/right hand thumb-impression of the member |
| Designation and Seal |
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Date.............................
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Encl.............................
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Affix Re. Revenue Stamp |
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| Signature or left/right hand thumb impression of the member |
| Head Clerk |
Assistant Commissioner/Regional Commissioner |
| Received the following claims: ........................................................ |
Registration No. .......................................................... |
| EPF........................................................................................... |
Date......................................................................... |
| FPF ........................................................................................... |
Official Seal ............................................................... |
| IF.............................................................................................. |
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| In case, no intimation is received within a month, you may write to the Complaints Officer, Employees' Provident Fund duly quoting the Registration Number and your Provident Fund Account Number. |
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Postage Prepaid |
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| .................................................. |
| .................................................. |
| PIN.............................................. |
1. All the columns on the form should be filled in completely, in ink, without any overwriting.
2. Against the column reason for leaving service, indicate the one applicable:
(a)Retired from service after attaining the age of 55 years/attained the age of 55 years.(b)Retired on account of permanent and total incapacity for work due to Bodily/Mental infirmity.(c)Retired under voluntary retirement scheme.(d)Migrating from India for permanent settlement abroad.(e)Leaving India at least for a year.(f)Retrenched from service.(g)Discharged from service on receiving compensation under the Industrial Disputes Act, 1947.(h)Resigned, not employed in any factory to which the Employees' Provident Fund Scheme applies.3. "Full postal address", should be given clearly in Block Letters since the M.O. & Payment intimation is to be sent to this address. The name of the member and Father's (Husband's) should also be furnished in this column. Correct postal address including pin code will enable the Commissioner to make prompt payment to the correct payee.
4. It is advisable to have the payment by cheque. For this purpose the account payee cheque will be sent direct to the Scheduled Bank in which the S.B. A/c is maintained under intimation to the member. This will expedite the settlement of the correct payee.
5. The literate member should sign the application form, illiterate male member should affix his left hand thumb-impression and illiterate female member should affix her right hand thumb-impression and the fact should be clearly recorded below thumb-impression.
6. If the claim is required to be submitted after completing the prescribed period (i.e., in case falling under items 2(g) and (h) above only), the declaration of non-employment in the application should be completed duly dated.
7. The claim application should be attested and forwarded by the employer under whom the member was last employed.
If the member is unable to send the application through the employer or duly attested by him for any reason whatsoever he may forward the claims duly signed in the presence of any one of the following authorised and got attested over his official seal.(i)Magistrate; (ii) A Gazetted Officer; (iii) Post/Sub-Postmaster; (iv) President of the Village Union; (v) President of the Village Panchayat where if no Union Board; (vi) Chairman/Secretary/Member of the Municipal/District Local Board; (vii) Member of Parliament/Legislative Assembly; (viii) Member of Central Board of Trustees/Regional Committees Employees' Provident Fund; (ix) Manager of the Bank in which the Savings Bank Account is maintained; (x) Head of any recognised educational institution; (xi) any authorised person as may be approved by the Commissioner.8. The following documents should be enclosed in support of the claim.
If the member retired on account of permanent and total incapacity due to bodily or mental infirmity a medical certificate from the ESI or if the employee is covered under the ESI Scheme from the Medical Officer designated by the Establishment should be attached.In case of migration from India for permanent settlement abroad Visa, Passport, Journey ticket, etc., should be sent for perusal and return.9. The member should also furnish the address in the acknowledgement card attached to the claim(s).
10. Instructions to the employer before forwarding the claims.
Details of contribution in respect of the member for the current financial year should be furnished in the certificate portion, in case, the contribution is not already paid it should be remitted by separate challan and receipted triplicate challan should be enclosed to the claim.11. In support of claim under Employees' Family Pension Scheme, 1971 the period of break in reckonable service (i.e., period for which EPF contribution is not payable) should be furnished if not already intimated through contribution card.
Note:-If claim in Form 10-B (EPF) along preferred S. Nos 2,6 & 8 are not applicable.FORM 20THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952Regn. No ......................(For Office use only)Form to be used:(1)by guardian of minor/lunatic member.(2)by a 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 Member(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(e)Date of leaving service(f)Reason for leaving service (in case of deceased member)(g)Date of death of the member(h)Marital status of the member on the day of deathParticulars of the claimant2. (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(d)Age (as on the date of death of the member)(e)Marital status (as on the date of death of the member)(Whether unmarried, married, widow, widower)(f)Relationship with the deceased member3. (To be filled by the guardian/manager of minor/lunatic member or lunatic minor *[nominee(s)/legal heir(s)]/family member(s) of the deceased 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 the Minor/lunatic Nominee(s)/Legal Heir(s)/Family Member(s) on whose behalf the Provident Fund Amount is claimed.
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Name |
Sex |
Age |
Religion |
Relationship |
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with the member |
with the guardian |
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| 3 |
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4. Claimant's Full Postal Address
Shri/Smt ................................(in block letters) S/o/W/o/H/o/D/o....................................PIN .........................
| 5. Mode of remittance |
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(Put a "tick" (√) in the box against the one opted) |
| (a) by postal money order at my cost |
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to the address given in Item No. 4 |
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| or(b) by account payee cheque sent direct for credit to my S.B. A/c. (Sch. Bank/Post Office) under intimation to me |
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*S.B. Account No...................................... |
| (Advance Stamped Receipt) |
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Bank.......................................................
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Branch....................................................
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Full address ofBank.................................
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Affix Re. 1 Revenue Stamp |
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| Signature or left/right hand thumb impression of the claimant |
| Month |
Contribution |
Period of break, if any |
Month |
Contribution |
Period of break, if any |
| Employee |
Employer |
Total |
Employee |
Employer |
Total |
| EPF |
FP |
EPF |
FP |
EPF |
FP |
EPF |
FP |
EPF |
FP |
EPF |
FP |
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| Head Clerk |
Assistant Commissioner/Regional Commissioner |
| Received the following claims: ........................................................ |
Registration No. .......................................................... |
| EPF........................................................................................... |
Date......................................................................... |
| FPF ........................................................................................... |
Official Seal ............................................................... |
| IF.............................................................................................. |
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| In case, no intimation is received within a month, you may write to the Complaints Officer, Employees' Provident Fund duly quoting the Registration Number and your Provident Fund Account Number. |
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Postage Prepaid |
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| PIN.............................................. |
1. Employees' Provident Funds Scheme, 1952: Form 20: Claim for the withdrawal of Provident Fund Accumulation of minor/deceased member. By whom the claim application should be preferred?
2. If the member is a minor by the guardian.
OROn death of the member:(a)If nomination subsists:-by the nominee(s); if the nominee(s) is/are minor by the guardian of minor(s).(b)If no nomination subsists: by the family members (family) includes posthumous child if any, except major sons, and married daughters whose husbands are alive, of the deceased member duly supported by list of surviving family members (as on the date of the death of the member) furnished by the last employer or mamlatdar/Tehsildar or Executive Magistrate indicating complete particulars such as name, relationship with deceased member (in the case of parents whether dependant or not), age, marital status. If any family member is a minor by the guardian of minor. If both (a) & (b) above are not applicable: by legal heir(s) duly supported by a legal heirship certificate (from the appropriate State normally Revenue authorities).3. Documents to be enclosed:
(a)If the application is preferred by a guardian other than the natural guardian or minor member/nominee/family member/legal heir a guardianship certificate issued by competent Court of law should be enclosed.(b)Death certificate.(c)If the amount receivable exceeds Rs. 5,000 but less than 25,000 an affidavit-cum-indemnity bond (Form may be obtained from the ex-employer of Regional Provident Fund Commissioner or Officer-in-Charge of Sub-Regional Office ........................) or Estate Duty Clearance Certificate.(d)If the amount receivable exceeds Rs. 25,000 an Estate Duty Clearance Certificate.Form 11 (FPF): Claim for benefits as admissible under the Employees' Pension Scheme, 1971. By whom claim application should be preferred?(1)If the member is minor by his guardian.OR(2)On death of the member:(i)If the deceased had "family" on the day of death the claim should be preferred by:(b)failing (a) above, by the guardian or eldest surviving minor son.(c)failing (a) and (b) above by the guardian or eldest surviving minor, unmarried daughter.(ii)If the deceased member had no family on the day of death, the Family Pension Fund benefit should be claimed by the person(s) eligible to receive the Provident Fund accumulation of the deceased member and if such member is a minor by the guardian.*(If the claimant being other than the natural guardian a guardianship certificate issued by the Court of law should be enclosed.)Important Note:-In case the member died while in service after contributing to the Family Pension Fund for a period of not less than two years, an application in Form 10-A should also be preferred for claiming monthly Family Pension.(iii)Form 5(F) "Benefit under Employees" Deposit-Linked Insurance Scheme, 1976.The benefit under Employees' Deposit-Linked Insurance Scheme, 1976 is admissible to the person(s) entitled to receive the Provident Fund Accumulation of the deceased member only under the following conditions :(1)The death should have occurred while in service; and(2)The average balance in the accounts of the deceased employee should not be below the sum of Rs. 1,000 during the preceding three years or during the period of his membership, whichever is less.An affidavit-cum-indemnity bond in the prescribed form should be furnished wherever the payment under Employees' Deposit-Linked Insurance exceeds Rs. 5,000 (if amount receivable under Employees' Provident Fund and Employees' Deposit-Linked Insurance does not exceeds Rs. 25,000 one affidavit-cum-indemnity bond is sufficient).GENERAL:(1)All the columns in the form should be filled in, in ink, without any overwriting.(2)Correct postal address, including PIN CODE will enable to make prompt payment to the correct payee.(3)The claimant should also furnish the address in the acknowledgement attached to the claims.(4)The literate claimant should sign the application form.In case of illiterate:-Left hand thumb-impression by illiterate male claimant and right hand thumb-impression by illiterate female should be affixed in the claim form.(5)Attestation of claim application: The application should be submitted through the employer under whom the member was last employed if for any reason, the claimant is unable to submit through the employer, the claim may be got attested with official seal by any one of the following officials: (i) Magistrate; (ii) A Gazetted Officer; (iii) Post/Sub-Postmaster; (iv) President of Village Union; (v) President of the Village Panchayat where there is no Union Board; (vi) Chairman/Secretary/Member of the Municipal/District/Local Board; (vii) Member of Parliament/Legislative Assembly; (viii) Member of C.B.T. Regional Committee of the EPF; (ix) Manager of the Bank where claimant has account; (x) Head of any recognised educational institution or; (xi) Any other official as may be approved by the Commissioner.(6)Instruction to employers:-While forwarding the claims the employer should ensure that all the information required in the claim is furnished correctly and requisite documents are enclosed in support of claim under Employees' Family Pension Scheme, 1971 the period of break in reckonable service (i.e., period for EPF contribution is not payable should be furnished, if not already intimated through contribution card).For office use onlyDated Official Seal andRegistration No............FORMS 21-30[Not printed]FORM 31Application for Advance from the Fund[Refer: Instructions](For office use only)Dated ...........................
| Purpose for which advance is required.......................... |
Official Seal and Registration No ............................................. |
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Amount of advance required (in words)...................................... |
1. Name in full (in block letters) ...................................................................................................
2. Father's/Husband's Name .......................................................................................................
3. Name of the factory/ establishment in which employed and address ...............................
4. Provident Fund Account No .....................................................................................................
5. Monthly basic wages & D.A. Basic+D.A. Total ......................................................................
6. Full postal address of the member to which payment/intimation is to be sent .................
7. Mode of remittance :
(a)In case of advance for purchase of site/house/ flat or construction through an agency OR repayment of housing loan, indicate(i)in whose favour the cheque is to be drawn, and(ii)full address .........................................................................................In other cases, put a tick ()against any one of the following :(b)By account payee cheque, through the (employer of the address given against Sl. No. 3)(c)By deposit in Bank Account No. in figures ..............................in words................... Name of the Bank ..........................................................................................(d)By money order at my cost to the address given against Sl. No. 6 ......................I declare that the advance is required to meet the expenses in connection with marriage of my son/daughter/brother/sister/Sri/Kumari .........................................................................[Name] aged ..................................to be celebrated on...........................at.......................................Date .............................................................address.............................................................I declare that the above particulars are true to the best of my knowledge and I will abide by the conditions governing the grant of advance under the scheme. Certificate(s)/document(s) in support of my application is/are furnished/enclosed.Station ...............................Date ...................................Signature/left hand thumb-impression of the member*Delete if the advance applied for is not for marriage.Advance Stamped Receipt[To be furnished with reference to 7(a) or (b) or (c) above only]Received a sum of Rs* ....................(Rupees............................) from the Regional Provident Fund Commissioner/Officer-in-Charge of Sub-Regional Office, Employees' Provident Fund towards the grant of advance from my Employees' Provident Fund Account mentioned by firm.
| To be filled by the E.P.F. office. |
Affix Re. 1 Revenue Stamp |
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| Signature of member |
| Designation of the signing officer with Stamp of the factory/ establishment |
Signature of the Employer or an Authorised Officer of the factory/ establishment |
| M.O. Commissioner, if any. |
Net Amount to be paid by M.O .......................................... |
| Clerk |
Head Clerk |
Account Officer |
| P.I.No............................................... |
Vide Payment scroll P.C. to A.O. |
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| Clerk |
Head Clerk |
Assistant Commissioner |
1. Purchase of a Dwelling site:
(From an "Agency": Original allotment order)From an individual:-Original title deed non-encumbrance certificate (for verification and return agreement with the seller).2. Purchase of Dwelling-house/ flat:
(From an "Agency": Original allotment order)(From an individual:-Original title deed (for verification and return) agreement with the seller, non-encumbrance certificate from appropriate authority that the house/: Q, is a new and unlived one furnishing the number and date of plan approval, commencement and completion of the house/ flat tax bill and receipts.)3. Construction of a House:
Original title deed for verification and return (non-encumbrance certificate estimated, cost of construction, Approval Plant.Note.-While claiming the second and subsequent instalment the declaration/certificate as required by the Commissioner in his letter sanctioning the advance should be submitted along with the application).Agency referred to in 1 to 3 above would mean Central/State Government, a cooperative society, an institution, a Trust, a Local Body or a Housing Finance Corporation in case of transaction through an agency the payment will be made only by account payee cheque direct to the "Agency" concerned.4. Addition, Alteration or Improvement to the House Owned by member or by Spouse:
(Approval of the appropriate authority, estimate of the work, original title deed of the house (for verification), non-encumbrance certificate, a certificate from the appropriate authority specifying the date of completion of the house).5. Repayment of (Housing) Loan to State Government Housing Board, Municipal Corporation or a body similar to Delhi Development Authority:
(A certificate from the lending authority furnishing the details of loan and outstanding amount).6. Closure/Lock-out of the Factory & Establishment, for reasons other than Strike:
(Furnish the Certificate "A" given overleaf)7. Non-Receipt of wages for 2 months:
(Furnish the Certificate "B" given overleaf)8. Illness of member/Family Member:
(Furnish the Certificate "C" given overleaf)9. Marriage of Self/Son/Daughter/Sister/Brother.
10. Post-Matriculation Education of Son/Daughter:
(certificate from the institution regarding the course of study and anticipated expenditure)11. Damage to the property due to Natural Calamity (Flood/Riot/Earthquake):
(Furnish the Certificate "D" given overleaf)12. Affected by cut in Electricity:
(Furnish the Certificate "E" given overleaf)13. Purchase of Equipment for physically Handicapped Member.
(Furnish the Certificate "F" given overleaf)Notes.-(1) Such other documents, certificates, etc., as may be required by the sanctioning authority are also required to be furnished, through the establishment.(2)In case no intimation is received within a month please write to the R.P.F.C./Officer-in-Charge of sub-regional office through the establishment.Certificate-A (Refer: Instructions SI. No. 6)Certified that no compensation was paid to the member Sri/Smt/................. for the period of lock-out/closure.Signature of the Employer/Authorised officer with date and sealCertificate-B (Refer: Instructions SI. No. 7)Certified that member Sri/Smt ............................................ has not received his/wages for a continuous period of two months or more, i.e., from ....................................... to....................Signature of the Employer/Authorised Officer with date and sealCertificate-C (Refer: Instructions Sl. No. 8)Certified that--(i)The member Sri/Smt .........................has/had been granted leave for a period of .................. from............... to....................(ii)The ESI facilities/cash benefits are not actually available to the member/the member has ceased to be eligible for cash benefits under ESI certificate from ESI enclosed.Signature of the Employer/Authorised Officer with date and sealMedical certificate to be issued (i) In case of major surgical operation or where the hospitalisation for one month or more had or has become necessary by the Doctor of the Government/ESI/Private Hospital (ii) In case of treatment of T.B./Leprosy, paralysis or cancer by Doctor of Govt./Private Hospital/ESI or by a Regd. Medical Practitioner (iii) In case of treatment of heart ailment or mental derangement by a special Doctor.Certified that Sri/Smt ...................................... S/o/W/o/D/o............................,.....(i)is suffering from T.B./Leprosy/Paralysis/Cancer/Mental derangement/Heart ailment.(ii)is suffering from ............................... (disease) for which a major surgical operation and hospitalisation for a period of ...................... days from ........................(iii)is suffering from ............................ and hospitalisation for a period ............. days from ....................... to................. had or has become necessary.Signature of Doctor with date and sealDelete whichever is not applicable.Certificate-D (Refer: Instructions SI. No. 11)Certified that the movable/immovable property of Shri/Smt ........................................ viz., .................. situated at ........................ has been damaged due to ................... on (date) .......................... The estimated loss of property due to ..................calamity is valued at Rs ................................ The State Government has declared that the calamity has affected the general public in the area in which the property of member is/was located vide Notification/Press release no ................ and date..................Signature of Employer/Revenue Officer/Gazetted Officer/Member or C.B.T./Regional Committee with seal and dateCertificate-E (Refer: Instructions Sl. No. 12)Certified that the fall in wages amounting to 25% more than 25% of the wages in respect of Shri/Smt ................... is due to power cut.Signature of the Employer/Authorised official with date and sealCertificate-F (Refer: Instructions Sl. No. 13)Certified that Shri/Smt/Km./.............................. S/o/W/o/D/o ...................is physically handicapped, viz. ............................ (nature of handicap) and requires the equipment, viz, ..................... costing about Rs..................... to minimise the hardship on account of handicap.Signature of the Doctor with date and seal
