Scribd Logo
Upload

Welcome to Scribd!

  • 32 views

    I I I I: 1it.f.t

    Uploaded by

    ilyaskureshi
    This document is a claim form for benefits under the Employees' Deposit-Linked Insurance Scheme, 1976. It requests information to process a claim for the deceased member's family. Section 1 asks for details of the deceased member like name, date of death, and last place of employment. Section 2 asks for details of the claimant/guardian filing the claim. Section 3 provides a stamped receipt for the approved payment amount. Section 4 requests bank account details for payment. Employers must certify member details and account balances. The form is used to process insurance payouts to eligible claimants of deceased provident fund members.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    I I I I: 1it.f.t

    Uploaded by

    ilyaskureshi
    32 views4 pages
    This document is a claim form for benefits under the Employees' Deposit-Linked Insurance Scheme, 1976. It requests information to process a claim for the deceased member's family. Section 1 asks for details of the deceased member like name, date of death, and last place of employment. Section 2 asks for details of the claimant/guardian filing the claim. Section 3 provides a stamped receipt for the approved payment amount. Section 4 requests bank account details for payment. Employers must certify member details and account balances. The form is used to process insurance payouts to eligible claimants of deceased provident fund members.

    Original Description:

    4521

    Original Title

    Form5IF

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a claim form for benefits under the Employees' Deposit-Linked Insurance Scheme, 1976. It requests information to process a claim for the deceased member's family. Section 1 asks for details of the deceased member like name, date of death, and last place of employment. Section 2 asks for details of the claimant/guardian filing the claim. Section 3 provides a stamped receipt for the approved payment amount. Section 4 requests bank account details for payment. Employers must certify member details and account balances. The form is used to process insurance payouts to eligible claimants of deceased provident fund members.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views4 pages

    I I I I: 1it.f.t

    Uploaded by

    ilyaskureshi
    This document is a claim form for benefits under the Employees' Deposit-Linked Insurance Scheme, 1976. It requests information to process a claim for the deceased member's family. Section 1 asks for details of the deceased member like name, date of death, and last place of employment. Section 2 asks for details of the claimant/guardian filing the claim. Section 3 provides a stamped receipt for the approved payment amount. Section 4 requests bank account details for payment. Employers must certify member details and account balances. The form is used to process insurance payouts to eligible claimants of deceased provident fund members.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 4

    ~ off.

    / Mobile Number
    <:TtITmsur/Clam I.D .
    lItF.H 1 It.f .t
    FORM5IF
    ~ f .IItq ~ 1ftwn"~. 1 978
    THE EMPLOYEES' DEPOSIT- LINKED INSURANCE SCHEME, 1 976
    ~ ~ iI"RT3rof 1 T~ om ~, ~ ~ ~ ~ t <IT \f f iif ; ~ iI"RTom ~, ~ ~ amtC f; ~ ~
    mol <lit ~ 1 ) ~ EiRT ~ lffiI "If f l ~, To be f illed up separately by each claimant. In case the claimant is minor
    it should be f illed up by the guardian on hislher behalf . Where there are more than one minor the guardian should
    claiminone Form on their behalf .
    fbquft - ~ J mT CJ it 'f f .l ~ m.~ CJ it ~ ~ ,Note - Read the "Instructions" caref ully bef ore completing this
    f orm
    1 . ~ ~ <liT f cm1 J r
    TheParticulars inrespect of the deceased member
    t;) ~~<IiT~
    (a) Name of the Deceased member
    g) f imT <liT 'Ill{("qf ct <liT 0f 1 1 i ~ ~ ~ l!T'f f i "4)
    (b) Father's Name (Husband's name inthe caseof married woman)
    (tr) ~~~
    I
    (c) Date of Death (ddlmmlyyyy) I
    1 11 1 11 1 1 1
    ~) ~ /~ <liT 'Ill{Cl"lf f iT ~ ~ 3lf .trol" "ijR m /
    (d) Name and Address of the Factory !Establishment
    where the member was last employed.
    ~)~M~~
    at./<IiT. <Ii1 '. ~~$off. IDf f i off.
    (e) Provident Fund Account No RO/Of f ice Code Estt. Code No. NcNo.
    I I I I
    2. ~/~ <liT f cm1 J r/ Details of the claimant/guardian.
    t;) Of J 1 !"/Name
    g) WI'I ~/ Date of Birth (ddlmrnlyyyy)
    (tr) ~ ~ ~ ~/ Relation with the deceased
    ~ f cm"uJ If th I d d 1 f th eIh ~ <liT ecalmant IS aguar ran, etalso emmor nomine eir
    ~ <liT 'Ill{/Name of the minor ~ <liT ~ ~ ~ ~/Relationship of the
    guardian with minor
    Claimant's Full Postal address (in block letters)
    .,f i/~/ Shn.lSmt. .
    ~/~/tlf ct/~/ Dol S/o W/O Hlo .
    .................................. J iR/Pin .
    ~ ~ ~/Signature of claimant f .t<J )qf f i ~ ~/Signature of Employer
    Form 5IF (www.epf india.gov.in)
    Page 1 of 4
    4 ~ ~ cm f f it Mode of remittance:
    ~ ~ q;<ff ~ ~ if f l{f <lIT<IT 'fi.(~ ~/~)
    Tj ~ ~ li~itl:lf 'lq; 1 J m1 1 f if anmrr <lIT<IT ~"4;m
    \iJ T1 ?/ By account payees cheque! electronic mode
    sent Direct f or credit to my S.B. NC (Scheduled
    Bank IPO) Under intimation to me
    ~ ~ <lIT<IT 'fi./
    S.B Account no .
    ~ q;J YIf Il/
    Name of the Bank .
    (~ "-lIM "$ ~/~ ~ 1 1 f T~ 1 If tt.
    ~ ill\" Please attach a copy of
    cancelled/blank C heque)
    WRlIT/Branch .
    WRlIT q;J WT mrr/ Full Address of the Branch .
    ~ <6 mTeR 3f ~ ~/zy:! ~ ~ ~ q;J f uJ R)
    (Signature or Lef t/Right hand thumb impression of the claimant)
    ~~.
    Advance Stamped Receipt
    ........................................... ~~ ~)cm~~~~~/~~~1 !if lIh;m
    ......................................................................................... ~ imT ~ ~ ~;j)1 :rr"lit\iAT"Rl"ll <6 <'it! "I'(~ ~ mff"l'( Vf 'lT <6 ~ >rJ 1{f ~I
    *Received asumof Rs ('Rupees only)
    f romRegional Provident Fund Commissioner/Of f icer-in-charge of sub Regional Of f ice by
    deposit inmy Saving Bank account towards the Employees' Deposit Linked Insurance benef it.
    ~ ~/
    ~ 6 ""RT 'lf f i ~ <6 ~ <mft ~ \i!RT ~
    *Thespace should be lef t blank which shall bef illed in
    by Regional Provident Fund Commissioner/Of f icer
    incharge of S.R.O.
    ~ 1 ~
    ~
    ~
    Revenue
    Stamp
    ~ <6 ~ ~ "iIttl"/GiII~ <6 ~ q;J f uJ R
    Signature or Lef tlRight hand thumb impression of the claimant
    Form 5IF (www.epf india.gov.in) Page 2 of 4
    lI'fI1If-~/ Certif icate
    (f .\ltIlIm J m 'RI' 'GIl1 l To be f urnished by the Employer)
    1 ~ f<I>m Wf f i t~~;l ~~ ~/~ f.mr'I f<I>m ~I ~ ~ ~ <rT ~ if; ~ ~~ tl
    Certif iedthat theclaimantishassigned/thumbimpressedbef oreme. I declare that the above particulars are true to the best of
    my knowledge.
    2. ~f cl;mWf f i~f cl;~q\)~~~~~q;f ~I
    Certif ied that the member died on while in service.
    3~<tRmiif cl;~~/~/~ .
    mm ~ q\) ~ ~ ~ ~/~/~ om ~ 'lml
    Certif ied that the Provident Fund accumulation of deceased employee, late Sh/Smt./Kumari .
    ..................................................... Ale. No were paid to ShrilSmt./Kumari
    (i)
    (ii)
    (iii)
    W >IT'<!~ if; ~ 'F"" ~ if; 'W!i<IR "!l'EiI cm ~ /~ "\!fa ~ I
    (The employer of exempted Establishment shall send on attested copy of the nomination of the deceased employee)
    ~ q\) ~ if; ~ ~ 1 2 ~ it ~ 1lrn" if; 3Rf ~ ~ if; ~ ~ ri -.'j it'! f <t<R"I !Balance inProvident Fund at
    theend of the month, proceeding the 1 2 months immediately proceeding the death of the member
    ~ ~ ~ ~ 1 952" Wmll ~ am 'ffi\iIf \//To bef illed in by employee of establishment exempted under
    EPF Scheme 1 952.
    ~. "ff./
    1lrn"/ Month
    3tmFI <t; G Frr ~1 \Rq';t i!ITGI/ ~/ ~ffl/
    S.No ~/ Both 'Il"'Rf i / Ref und Interest Withdrawals Progressive
    shares of of withdrawal Balance
    Contribution
    l.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.
    1 0.
    ll.
    1 2.
    ~/Total
    1 2 lIMq;r iiI'R?
    Total of l2 Months
    ~~it'!f .
    Provident Fund Balance f .
    ~it'!~ .
    Average Balance ~ .
    ~ ~ ~ ~ ~ . "IT '! 0l!.T T 'IG'f lll)
    Signature of theemployer (Name &designation with of f icial Seal)
    ~Date
    #~ ~ ~it q;rc ~ Delete, if not applicable
    ~ : 3lW >IT'<!~ if; ~ am ~ ~ 2 'ffi\ifAT ~ af t< W m'<f ~ if; ~ cm 'ff4t R ~ ~ I
    Note: The employer of un-exempted establishment should f ill in the column 2 only and the employer of exempted
    establishment should f ill inthe all columns.
    Form 5IF (www.epf india.gov.in) Page 3 of 4
    (~ iIRlf <;rq <f ; wWr ~
    (For the useof Commissioner's Of f ice)
    q;f l\ 21-11/9 ~) 1 <ft.f.t m.n ~ ~ 1\ G \it ~ ~ ~I
    Entered inForm21 -N9 (Revised) 1 I.F. withdrawal Register
    ~.~~.
    SSA
    ~<f ;~
    (Under r )
    "T "fR >!G msm
    P.!' No .
    AccountNo .
    ~
    Section .
    ........................................................ ~ ~ ~ <C I~"T "fR ~~ 'Im<C I~ m.n~
    ~/~/~ <f ; ~ le!; ~ 1\ \ijlff ~ ~ am<C l\jffI;[ Wf 1 I; le!; >'i t I
    Passed f or payment f or ~ ~ , ) and the
    amount may beremitted f or credit to the Saving Bank Account No in respect of
    Sh.lSmt.lKumari maintained at (Bank)
    ~ ~I Accounts Of f icer
    ~I Date: .
    $I; ~ 'ff ~ bRT "T "fR f cI;m 'l<ITI
    Paid by inclusion incheque No.
    lIT.~~.
    SSA
    ~~
    SS
    X 'l.3Tf . / el.3Tf
    A.CIR.C
    Form 5IF (www.epfindia.gov.in ) Page 4 of 4

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy