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Employees' Provident Fund Organisation

(-'ll'd1" 'tTcr m71R ~ , m«=r fficfilT)
(Ministry of Labour & Emp loyment, Govt. Of India)
~ ~ I Head Office
~ ~mr.r," 14, ~ i f i r n T ~, ;,$"~ -110066.
Bhavishya Nidhi Bhawan, 14-Bhikaiji Cama Place, New Delhi-110066
www.epfindia.gov .in www.epfindia.nic.in
Telephone: 011- 26713254 Fax: 011-26166609 Email: acc.fa.imc@epfindia.gov.in

No : Manual/Amendment/201 ~ Date:
2 17
To t\60 t)
All Addi. CPFC (HQ/Zone),
Regional P.F. Commissioners-incharge of
Regional Offices.

Sub: Composite Claim Form for Death Case to replace erstwhile Form No. 20,10-D &
5-IF - Revised Claim Form thereof
Ref: HO circular No. Manual/ Amendment/2011/163 dated 03.03.2017 (placed on EPFO
:,,vebsite at SI. No. 675 'Office order/Circulars' for the year 2016-17).

Sir,

The Central Provident Fund Commissioner vide order dated 03.03.2017 had
introduced Composite Claim Form for Death case by replacing erstwhile claim Form Nos. 20,
10-D and 5-JF with a view to simplify the submission of claim forms by the subscribers.

2. Based on various suggestions, the Composite Claim Form for Death cases has been
reviewed and accordingly a revised Composite Claim Form for death cases, approved by
CPFC, is attached herewith. This claim form shall come into force from the date of issue of this
circular.

(This issues with the approval of FA&CAO)

Yours faithfully,
Encl: As above

(Udita ~ )
Addi. CPFC (F&A)
 ~~F.l'Rl'~ www eofindia aov in
EMPLOYEES' PROVIDENT FUND ORGANISATION ~ ' I ".
1l<"J m>r.t * ~ r;r<IT ll'f;J Mobile No.
Composite Claim Form in Death Cases
v<r.J -20 (,nlts,J fllflt ~ v<r.J 10-~ (~/v<r.J - 5 ~ ( ~
[Form-20 (PF Payment)/Form-10-0 (Pension)/ form - 5 IF (EDU)]

1
(ofto!T1J:!'T, 3"'l1:~:'-,~ (i) ~Fr®! (ii) ~r.r/ Pension ( ) I (iii) '41m (~3!1$')
Tick whichever is/are applicable Provident Fund ( ) ~r.r .:rar .;r ~/Type of Pension claim : Insurance EDU) ( )

2 ~ ~"" =<.-t m;:t lt):

Name of the deceased member fin CAPITAL letters)
(a)~"" 'Im I Father's Name : a)
3
(b) ef.'1/<ri.!t .;r 'Im/ Spouse's Name : b)
~~*1~~ /
4
Marital status of deceased member
a) ~ ~ if;! 3!1tlR .m: (~ 3'lmU !'Tl
Aadhar Number of the deceased member (if available)
5 b) '!,l'.lln. / Universal Account Number (UAN)
c) ,nlts,J ~ =
,ram (~ '!,l',lln. 3'lmU ~
Number (in case UAN not available)
t) I PF Account

mo

.
6 im;t *t ~ ' Date of Leaving service
a)Whether Scheme Certificate has been issued (Yes/No)
iF'1T Fl;m = :;mi f.!;,rr 7J'llT t ~f.lffe)
b)lf Yes , Number of Scheme Certificate
7
~tlf,Fl\mlmTVT'R~=
c)Scheme Certificate issuing office
Fl\mlm1VT'R:;mi~~~if,1'1ffi<f'«IT

8
m Jilrsnft mo ~ 3@fft (>r<t~lft'I) , Period of Non-Contributory
service (Year/Month/Days) - (To be filled bv the emo!over)
9 ~ *1 'F"! ~ ~ ' Date of death of the member
iF'1T ~ <!s't 'F"! ~ ;l; mr.r st ,l\ (~f.lffe}/
10
Whether the member had died while in service(Yes / No)
~ f.lfll' ~r.r om 1\J!T (f~'Q,U!T$°) f<J ~ ;i;T ~ / CLAIMANT'S DETAILS FOR PROVIDENT FUND, PENSION AND INSURANCE (EDU)
~ .,rcma;; r.n1'1lf.'t "'"'P\ ~ / zj.n';r ~ .l< ~ .;r flnw>r ~ ~ .:raT ~ f.l;m 7TllT t I
*Perticulars of the claimant/minor/ nominee(s)/legal heir(s)/surviving family member on whose behalf the claim is submitted

~ ,ia'tr Relationship with

~/Father's / a!r1f ~
9".'11'.
'Im/ Name if;!
3!1tlR om:/ Frm ~ ~;l;
ef.'t.q'i-l\ 'Im/ ~

11
S.N .
Spouse's Name
Aadhar Number Gender
Date of
Birth
Marital
Status
=
Member
Guardian

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.

~ f.lfll' om $3trr.r311$' (~) il; ~ tcJ fif; m ~ ~ Bank Account details for payment of PF & EDU:
~tiJff~if;!~ Claimant- I Claimant -II Claimant -Ill
Bank Account details for oavment ~-I ~-11 ~-Ill
am, Name

12 i"iln h =
Saving Bank Account No.
ffi>m

h".;r'lma'«!T
Name & address of the Bank
mtQ'll,l'<fm
IFS Code of Bank
~r.r f<J fif; 'IJTc!T f<nRur / BANK ACCOUNT DETAILS FOR PENSION
~ tiJ ff ~ if;! !n'"{vr Claimant- I Claimant -II Claimant -Ill Claimant - IV
Bank Account details for ~-I ~-II ~-Ill ~-JV
oavment
am,Name

13 i"iln f f = ,j-...rr
Savino Bank Account No.
h.;r'lmo'«IT
Name & address of the Bank
mtQ'll,l'<fm
IFS Code of Bank
~.;rtr;=m.;r=
14 Full Postal address of claimant
li!r.l'I Pin ......... .......... ..........

~ ll1l1fiiln f.f;m ;;JJnT t f.'I; ~ f<nRur ~ ~ ~ ~ mr t

Certified that the particulars are true to the best of my knowledge.
~<lil~IITT
Claimant's signature ~ <lil~IITT
Employer's Signature
.wr Name: ~<lil~nllT':lo1'
Designation & Seal of Employer
~/Enclosures i) 1l?l"
C ~
111lJUTt!,f/ Death Certificate
ii) <l':HT ~ <Iii ~ <m:r I Joint photograph of all the claimants
iii) zyrr ~ ~ ~ ~ ;;\rl, <Iii = / Date of Birth certificate of children claiming pension
iv) ~ = (~ rll1!, trr) Scheme Certificate (if applicable)
v) k ~ ~ = ~ Viii' n- .:!-<ii ~ ~ ~ llof
a copy of cancelled cheque or attested copy of first page of bank Pass Book.
<lit ~ ~ ' For verification of bank accounts,