561[The Scheme, shall, in its application to International Workers as defined in this paragraph, be subject to the following modifications, namely
(1) For clause (f) of Paragraph 2, the following clause shall be substituted, namely
562[(f) excluded employee means,
(i) an International Worker, who is contributing to a social security programme of his country of origin, either as a citizen or resident, with whom India has entered into a social security agreement on reciprocity basis and enjoying the status of detached worker for the period and terms, as specified in such an agreement; or
(ii) an International Worker, who is contributing to a social security programme of his country of origin, either as a citizen or resident, with whom India has entered into a bilateral comprehensive economic agreement containing a clause on social security prior to 1st October, 2008, which specifically exempts natural persons of either country to contribute to the social security fund of the host country;]
(2) After clause (j) of Paragraph 2, the following clause shall be substituted, namely
(ja) International Worker means,
(a) an Indian employee having worked or going to work in a foreign country with which India has entered into a social security agreement and being eligible to avail the benefits under a social security programme of that country, by virtue of the eligibility gained or going to gain, under the said agreement;
(b) an employee other than an Indian employee, holding other than an Indian passport, working for an establishment in India to which the Act applies:
563[Provided that the worker who is a Nepalese national on account of Treaty of Peace and Friendship of 1950 and the worker who is a Bhutanese national on account of India-Bhutan Friendship Treaty of 2007, shall be deemed to be an Indian worker;]
(3) For Paragraphs 26, 26-A and 26-B, the following paragraphs shall be substituted, namely
26. Class of International Workers entitled and required to join the Fund. (1)(a) Every International Worker (other than an excluded employee), employed as on 1st day of October, 2008, in an establishment to which this Scheme applies, shall be entitled and required to become a member of the Fund with effect from the 1st day of November, 2008.
(2) Every International Worker (other than an excluded employee), employed after the 1st day of October, 2008 in an establishment to which this Scheme applies, who has not become a member already shall be entitled and required to become a member of the Fund from the date of his joining the establishment.
(3) Where the Scheme applies to an establishment on the expiry or cancellation of an order of exemption under Section 17 of the Act, every International Worker who, but for the exemption would have become and continued as a member of the Fund shall become a member of the Fund forthwith.
(4) An excluded employee of an establishment to which this scheme applies shall, on ceasing to be such an employee, be entitled and required to become a member of the Fund from the date he ceases to be such employee.
(5) On re-election of a class of International Workers exempted under Paragraph 27-A to join the Fund or on the expiry or cancellation of an order under that paragraph, every International Worker, who but for such exemption would have become and continued as a member of the Fund, shall forthwith become a member thereof.
(6) Every International Worker who is a member of a private provident fund maintained in respect of an exempted establishment and who, but for the exemption, would have become and continued as a member of the Fund shall, on joining an establishment to which this Scheme applies, become a member of the Fund forthwith.
26-A. Retention of membership. A member of the Fund shall continue to be a member until he withdraws under Paragraph 69 the amount standing to his credit in the Fund or is covered by a notification of exemption under Section 17 of the Act or an order of exemption under Paragraph 27 or 27-A or the benefits are settled in terms of the relevant provisions under the social security agreement entered into between India and his country of origin.
564[26-B. Resolution of doubts. If any question arises as to whether an International Worker is entitled to, or required to become, or continue as, a member, or as to the date from which he is entitled or required to become a member, the same shall be referred to the Regional Provident Fund Commissioner who shall decide the same:
Provided that both the employer and the International Worker shall be heard before passing any order in the matter and such hearing, if any, shall be in India.]
(4) In Paragraph 29, in sub-paragraph (1), after the points, the following proviso shall be inserted, namely
Provided further that where wages are paid in a currency other than in the Indian Rupee, the rate of conversion of that currency shall be the telegraphic transfer buying rate offered by the State Bank of India established under the State Bank of India Act, 1955 (23 of 1955) for buying such currency on the last working of the month for which the wages are due. .
(5) For Paragraph 36, the following paragraph shall be substituted, namely
36. Duties of employer. (1) Every employer of an establishment to which this Scheme applies shall send to the Commissioner within fifteen days from the application of the Scheme to such establishment, a consolidated return in such form as the Commissioner may specify, of the International Workers (indicating distinctly the nationality of each and every International Worker) required or entitled to become members of the Fund showing the basic wage, retaining allowance (if any) and dearness allowance including the cash value of any food concession paid to each of such International Worker:
Provided that if there is no International Worker who is required or entitled to become a member of the Fund, the employer shall send a NIL return.
(2) Every employer shall send to the Commissioner, within fifteen days of the close of each month, a return
(a) in Form 5 of the International Workers qualifying to become members of the Fund for the first time during the preceding month together with the declarations in Form 2 furnished by such qualifying International Workers (indicating distinctly the nationality of each and every International Worker), and
(b) in such form as the Commissioner may specify, of the International Workers (indicating distinctly the nationality of each and every International Worker) leaving service of the employer during the preceding month:
Provided that if there is no International Worker qualifying to become a member of the Fund for the first time or there is no International Worker leaving service of the employer during the preceding month, the employer shall send a NIL return. :
565[Provided further that a copy of the forms as mentioned in clauses (a) and (b) above shall be provided by the employer to concerned employees immediately after joining the service or at the time of leaving the service, as the case may be.]
(6) For Paragraph 69, the following paragraph shall be substituted, namely
69. Circumstances in which accumulations in the Fund are payable to an International Worker. (1) An International Worker may withdraw the full amount standing to his credit in the Fund
(a) on retirement from service in the establishment at any time after the attainment of 58 years;
(b) on retirement on account of permanent and total incapacity for work due to bodily or mental infirmity duly certified by the medical officer of the establishment, or where an establishment has no regular medical officer, by a registered medical practitioner designated by the establishment:
Provided that
(i) where an establishment has been closed, the certificate of any registered medical practitioner may be accepted;
(ii) where the establishment is covered by the Employees' State Insurance Scheme, medical certificate from a medical officer of the Employees' State Insurance Dispensary with which or from the Insurance Medical Practitioner with whom the employee is registered under the Scheme, shall be produced;
(iii) where by mutual agreement of employers and employees, a Medical Board exists for any establishment or a group of establishments, a certificate issued by such Medical Board may also be accepted for the purposes of this sub-paragraph.
(2) It shall be open to the Regional Commissioner to demand from the member a fresh certificate from a Civil Surgeon or any doctor acting on his behalf where the original certificate produced by him under clause (b) of sub-paragraph (1) gives rise to suspicion regarding its genuineness:
Provided that the entire fee of the Civil Surgeon or any doctor acting in his behalf shall be paid from the Fund in case the findings of the Civil Surgeon or any doctor acting on his behalf agree with the original certificate, and that where such doctor acting in his behalf agree with the original certificate, and that where such findings do not agree with the original certificate, only half of the fee shall be paid from the Fund and the remaining half shall be debited to the member's account.
(3) A member suffering from tuberculosis or leprosy or cancer, even if contracted after leaving the service of an establishment on grounds of illness but before payment has been authorised, shall be deemed to have been permanently and totally incapacitated for work.
566[(4) In respect of a member covered under social security agreement entered into between Government of India and any other country, on ceasing to be an employee in an establishment covered under the Act.] .
(7) For Paragraph 72, the following paragraph shall be substituted, namely
72. Payment of Provident Fund. (1) When the amount standing to the credit of a member becomes payable, it shall be the duty of the Commissioner to make prompt payment as provident in the Scheme.
567[(2) The due amount in respect of the member shall be payable in the payees' bank account directly or through the employer.]
(3) In all the other cases, the amount due shall be payable to the credit of the payee's bank account in India. .
(8) After Paragraph 78, the following paragraph shall be inserted, namely
78-A. Performing certain special functions under social security agreements. The Commissioner shall perform all such functions as are assigned to the Employees' Provident Fund Organisation under a social security agreement entered into between by the Government of India and any other country, in the manner and as per the terms specified therein. .]
568[Form 1
The Employees' Provident Funds Scheme, 1952
Exemption under Paragraph 27 of the Scheme
I hereby apply for exemption from the operation of all or the following provisions of the Scheme:
(a) . . . . . . . . . . . . . . . . . . . . . . .
(b) . . . . . . . . . . . . . . . . . . . . . . .
(c) . . . . . . . . . . . . . . . . . . . . . . .
(d) . . . . . . . . . . . . . . . . . . . . . . .
(e) . . . . . . . . . . . . . . . . . . . . . . .
1. Name. . . . . . . . . . . . . . . . . .
(in block letters)
2. Occupation. . . . . . . . . . . . . .
3. Sex . . . . . . . . . . . . . . . . . . . .
4. Religion . . . . . . . . . . . . . . . . .
5. Father's Name. . . . . . . . . . . .
6. Husband's name (for married women only) . . . . . . . . . . . . . . . . . .
7. Permanent Address . . . . . . . . . . . . . . . . . .
8. Details of the Provident Fund, gratuity or old age pension. . . . . . . . . . . . . . . . . .
I declare that all the particulars stated above are true to the best of my knowledge and belief.
Dated . . . . . . . . . . . . . . . . . . . . . 20
569[Signature or left hand thumb impression in case
of both female and male members of the Fund.]
Certified that the above declaration has been signed by . . . . . . . . . employed in . . . . . . . . . before me and that he/she is getting the benefits of provident fund, gratuity or old age pension as above.
Dated . . . . . . . . . . . . . . . . . . . . . . . . .
Signature of the Manager or other
authorised officer of the Factory/Establishment.
Registered No. of the Factory/
Establishment.]
Here give the name and address of the factory or other establishment in which employed.
Form 2 (Revised)
[Paragraphs 33 & 61(1) of the Employees' Provident Funds Scheme, 1952 and Paragraph 18 of the Employees' Pension Scheme, 1995]
Nomination and Declaration Form for Unexempted/Exempted Establishments
1. Name (in block letters)
2. Father's/Husband's Name
3. Date of Birth
4. Sex.
5. Marital Status
6. Account No.
7. Address:
Permanent
Temporary
8. (A) Date of Joining of EPF Scheme, 1952
(B) Date of Joining of EPF Scheme, 1971
(C) Date of Joining of EPF Scheme, 1995 .
PART A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death:
| Name of the nominee/nominees |
Address |
Nominee's relationship with the member |
Date of Birth |
Total amount or share of accumulations in Provident Fund to be paid to each nominee |
If the Nominee is a minor, name & relationship & address of the guardian who may receive the amount during the minority of nominee |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
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1. *Certified that I have no family as defined in Para 2(g) of the Employees' Provident Funds Scheme, 1952 and should I acquire a family hereafter the above nomination should be deemed as cancelled.
2. *Certified that my father/mother is/are dependant upon me.
*Strike out whichever is not applicable.
Signature or thumb impression of the subscriber.
PART B (EPS)
(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children Pension in the event of my death.
| Sl. No. |
Name & Address of the family member |
Address |
Date of Birth |
Relationship with the member |
| (1) |
(2) |
(3) |
(4) |
(5) |
| 1. |
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*Certified that I have no family as defined in Para 2(vii) of the Employees' Pension Scheme, 1995 and should I acquire a family hereafter, I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension admissible under Para 16(2)(a) (i) & (ii) in the event of my death without leaving any eligible family member for receiving pension.
| Name & Address of the nominee |
Date of Birth |
Relationship with the member |
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Date:
| *Strike out whichever is not applicable. |
Signature or thumb impression of the subscriber. |
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt/Km . . . . . . . . . . . . . . . . . . . . . . employed in my establishment after he/she has read the entries. The entries have been read over to him/her by me and got confirmed by him/her.
| |
Signature of the employer or other authorised officer of the establishment |
| Place . . . . . . . . . . . . . . . . |
Designation . . . . . . . . . . . . . . |
| Date . . . . . . . . . . . . . . . . |
Name and Address of the Factory/ Establishment or rubber stamp thereof. |
570[Form 3
(For Unexempted Establishments only)
(Paragraphs 35 and 42 of the Employees' Provident Funds Scheme, 1952)
Contribution card for the currency period from . . . . . . . . . . . to . . . . . .
1. Account No.
2. Name . . . . . . . . . . . . . . . . Surname
(In Block Capitals)
3. Father's/Husband's name
4. Name and address of Factory/Establishment
5. Statutory rate of contribution
6. Voluntary higher rate of employee's contribution, if any
7. Age
8. Occupation/Job
9. Income per month
10. Permanent/Temporary/Contractual
| |
Contributions |
Refund of |
Break in membership/reckonable service |
Remarks |
| Months |
Member's Share |
Employer's Share advance |
advance |
| E.P.F. |
F.P.F.at |
TOTAL |
E.P.F. |
F.P.F.at |
TOTAL |
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1-1/6% |
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1-1/6% |
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RsP |
RsP |
RsP |
RsP |
RsP |
RsP |
RsP |
From |
To |
| April |
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| May |
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| TOTAL |
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| Dated. . . . . . . 20. |
Signature of the Employer (Office Seal)] |
Form 3-A (Revised)
(For Unexempted Establishments only)
(Paras 35 & 42 of the Employees' Provident Funds Scheme, 1952 and Para 19 of The Employees' Pension Scheme, 1995)
Contribution Card for the currency period from 1st April, 20 . . . . . . . . . . . . . to 31st March, 20. . . . . . . .
1. Account No.
2. Name/Surname (in block capitals)
3. Father's/Husband's Name
4. Name & Address of the Factory/Establishment
5. Statutory rate of the Contribution
6. Voluntary higher rate of employee's contribution, if any
| |
Contributions |
|
| Months |
Worker's share |
Employer's share |
Refund of advance |
No. of days/period of Service non-contributing (if any) |
Remarks |
| |
Amount of wages |
E.P.F. |
E.P.F. difference between 10% 12% & 8.33% (if any) |
P.F. contribution 8-1/3% |
|
| 1 |
2 |
3 |
4(a) |
4(b) |
5 |
6 |
7 |
| March paid in April |
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(a) Date of leaving service, ifany |
| 1 |
2 |
3 |
4(a) |
4(b) |
5 |
6 |
7 |
| May |
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(b) Reasons for leaving service, if any |
| June |
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| July |
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| Aug |
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| Feb. |
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| Feb. paid in March |
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| TOTAL |
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Certified that the total amount of contributions (both shares) indicated in this card i.e. Rs . . . . . has already been remitted in full in EPF A/c No. 1 and Pension Fund A/c No. 10 . . . . . . . . . . . . (vide note below).
Certified that the difference between the total of the contribution shown under Cols. 3 & 4(a) & 4(b) of the above table and that arrived at on the total wages shown in Column 2 at the prescribed rate is solely due to rounding off of contributions to the nearest rupee under the rules.
| Dated . . . . . . . . . . 20 |
Signature of the Employer with Office Seal |
. Rates now enhanced by EPF (Amendment) Act, 1998.
Note. (1) In respect of the Form (3-A) sent to the Regional Office during the course of the currency period for the purpose of final settlement of the accounts of the member who has left service, details of date and reasons for leaving service should be furnished under col. 7(a) & (b).
(2) In respect of those who are not members of the Pension Fund, the employer's share of contribution to the EPF will be 12%, 10% or 8.33% as the case may be and is to be shown under Column 4(a).
Form 4
(Paragraphs 35 and 42 of the Employees' Provident Funds Scheme, 1952)
Contribution card for employees other than monthly paid employees for the period from . . . . . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . .
1. Account No.
2. Name (in block capitals) Surname
3. Caste
4. Sex
5. Date of birth as given in Form 2
6. Occupation
7. Father's name
8. Husband's name
(for married women only)
9. Marital status
(whether bachelor, spinster, married, widow or widower)
10. Permanent Address
Village .Thana Taluk/Sub-Division
District .State .
11. Signature or left hand thumb impression of member
12. Signature of person preparing the card
13. Signature of the Manager of the 571[factory or other establishment]
14. Registered Number of the 572[factory or other establishment]
15. Name and address of the 573[factory or other establishment]
Particulars of employment
| Registered number of factory or other establishment |
Duration of Employment |
Remarks |
Initials of the employer's authorised clerk |
| From |
To |
|
| The employer's and member's contribution should be shown separately for each week |
Employer's/member's total amount refunded |
week 1 |
week 2 |
week 3 |
week 4 |
week 5 |
week 6 |
| week 7 |
week 8 |
week 9 |
week 10 |
week 11 |
week 12 |
week 13 |
week 14 |
week 15 |
week 16 |
week 17 |
| week 18 |
week 19 |
week 20 |
week 21 |
week 22 |
week 23 |
week 24 |
week 25 |
week 26 |
week 27 |
week 28 |
| week 29 |
Week 30 |
week 31 |
week 32 |
week 33 |
week 34 |
week 35 |
week 36 |
week 37 |
week 38 |
week 39 |
| week 40 |
week 41 |
week 42 |
week 43 |
week 44 |
week 45 |
week 46 |
week 47 |
week 48 |
week 49 |
week 50 |
| week 51 |
week 52 |
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| Total contribution of the employer Total contribution by the member Grand Total Amount refunded |
Rs. P. |
Signature of the employer's Head Clerk or any Authorised Clerk Checked and found correct. Authorised official of the Office of the Commissioner |
Form 4-A
574[* * *]
Form 5
[Paragraph 36(2)(a) of the Employees' Provident Funds Scheme, 1952 and Para 20(4) of the Employees' Pension Scheme, 1995]
Return of Employees qualifying for membership of the Employees' Provident Fund, Employees Pension Fund & Employees' Deposit-Linked Insurance Fund for the first time during the month of . .
(To be sent to the Commissioner with Form 2 (EPF & EPS)
Name and Address of the Factory/Establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Code No. of Factory/Establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Sl. No. |
Account No. |
Name of the Employee (in block capitals) |
Father's name (or Husband's name in case of married woman) |
Date of Birth |
Sex |
Date of joining the Fund |
Total period of previous service as on the date of joining the Fund (Enclose Scheme certificate if applicable) |
Remarks |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
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Signature of the Employer or other authorised officer
of the Factory/Establishment.
Stamp of the Factory/Establishment
Date . . . . . . . . . . . . .
Form 5-A
(For exempted/unexempted Establishments)
(Paragraph 36-A of the Employees' Provident Funds Scheme, 1952 and Paragraph 21 of the Employees' Pension Scheme, 1995 and Paragraph 1 of the Employees' Deposit-linked Insurance Scheme, 1976)
Return of Ownership to be sent to the Regional Commissioner (IN DUPLICATE)
1. Name of the establishment
2. Code Number of the establishment under the U.P./Employees' Provident Funds and Miscellaneous Provisions Act, 1952
3. Postal address of the establishment and its branches/departments, if any
4. Industry or business in which engaged
5. Date of first commencement of production/business (Trial/Regular)
6. Date of closure by the previous management
7. Whether run by the owners or lessees (if by lessees, period of the lease should be indicated)
8. Particulars of owners
| Name |
Age |
Status* |
Father's name |
Residential address |
Date from which in position |
| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
| (i) |
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| (ii) |
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| (iii) |
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*Whether Proprietor, Partner, Managing Partner, Managing Director, Director
9. If on lease, particulars of lessees:
| Name |
Age |
Father's name |
Residential address |
Date from which in position |
| (a) |
(b) |
(c) |
(d) |
(e) |
| (i) |
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| (ii) |
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| (iii) |
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10. If registered under the Factories Act, particulars of the Manager/Occupier.
| Name |
Age |
Father's name |
Residential address |
Date from which in position |
| (a) |
(b) |
(c) |
(d) |
(e) |
| A. Occupier |
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| B. Manager |
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11. Particulars of the persons mentioned above, who are in charge of and responsible for the conduct of the business of the establishment.
| Name |
Age |
Father's name |
Residential address |
| (a) |
(b) |
(c) |
(d) |
| (i) |
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| (ii) |
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| (iii) |
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Signature of the Employer
Designation
Seal of the establishment
Dated . . . . . . . . . . . . . 20 . . . .
Note. Any change in the information given above should be intimated in writing to the Regional Commissioner within fifteen days of such change by registered post and in the prescribed manner under copy to the Provident Fund Inspector.
Form 6 (Revised)
(Paragraph 43 of the Employees' Provident Funds Scheme, 1952)
Return of the Contribution Cards sent to the Commissioner on the expiry of the period of currency from the . . . . . . . . . . . . . . . . . to the. . . . . . . . . . . . . . . . . . .
Name and Address of the Factory/Establishment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Code No. of the Factory/Establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Sl. No. |
Acc-ount No. |
Name of the member (in block letters) |
Employer's Total Contribution |
Members' Total Contribution |
Amount refunded |
Remarks |
| E.P.F. |
F.P.F. |
TOTAL |
E.P.F. |
F.P.F. |
TOTAL |
|
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| at 11/6% |
at 11/6% |
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| |
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Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
|
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| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
| |
|
|
|
|
|
|
| Total number of cards sent . . . . . . . . . . . . . . . . . |
Signature of the Employer or other authorised officer of Factory/Establishment. |
| |
|
| Date. . . . . . . . . . . . 20 |
Stamp of the Factory/Establishment |
Form 6-A
[Paragraph 43 of the Employees' Provident Funds Scheme, 1952 and Paragraph 20(4) of the Employees' Pension Scheme, 1995]
Annual statement of contribution for the current period from 1st April .to 31st March .. ..
| Statutory rate of contribution %. . . . . . . . |
| Name and address of the Factory/Establishment . . . Code No. of the Factory Establishment . . . . . . . . . . . . . . |
No. of Members voluntary contributing at a higher rate . . . . . . . . |
| Sl. No. |
Account No. |
Name of the Member (in block letters) |
Wages, Retaining allowance (if any) and D.A. including cash value of food concession paid during the currency period |
| 1 |
2 |
3 |
4 |
| |
|
|
|
| |
|
|
|
| Amount of Worker's Contributions deducted from the wages E.P.F. |
Employer's Contribution w.e.f. 16-11-1995 |
Refund of Advance |
Rate of higher voluntary contribution (if any) |
Remarks |
| E.P.F. differences between 12% or 10%-8-1/3% |
Pension Fund Contribution 8-1/3% |
| 5 |
6 |
7 |
8 |
9 |
10 |
| |
|
|
|
|
|
| |
Total Rs. |
Rs. |
Rs. |
Rs. |
Reconciliation of Remittances
| Sl. No. |
Month |
Amount Remitted |
(Adm. Charges Rs. At 0.65% of wages) |
EDLI Admn. Charges 0.01% A/c No. 22 |
Aggregate Contrib-utions Cols. 5+6+7 Rs. ( ) |
| EPF Contribution including refund of advances A/c No. 1 |
Pension Fund Contrib-ution A/c No. 10 |
EDLI Contrib-ution A/c No. 21 |
(Admn. Charges A/c No. 2 |
| 1. |
Mar. Paid in Apr. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 2. |
May |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 3. |
June |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 4. |
July |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 5. |
August |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 6. |
Sept. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 7. |
October |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 8. |
November |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 9. |
December |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 10. |
January |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 11. |
February |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 12. |
Feb. paid in Mar. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 13. |
Arrear, if any |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
| 14. |
|
|
|
|
|
|
|
| |
TOTAL |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Rs. |
Remarks: (1) Total number of contribution cards enclosed (Form 3-A Revised).
(2) Certified that Form 3-A, duly completed, of all the members listed in this statement are enclosed, except those already sent during the course of the currency period for the final settlement of the concerned member's account vide Remarks furnished against the names of the respective members above.
Signature of Employer (with Office Seal)
Notes. (1) The names of all the members, including those who had left service during the currency period, should be included in this statement. Where the Form 3-A in respect of such members who had left service was already sent to the Regional Office for the purpose of final settlement of their accounts, the fact should be stated against the members in the Remarks column above thus:
Form 3-A already sent in the month of . . . . . . . . . . . . . . . . 20 .
(2) In case of substantial variation in the wages/contributions of any members as compared to those shown in the previous month's statement the reason should be explained adequately in the Remarks column.
(3) In respect of those members who have not opted for Pension Fund their entire employer's contribution @ 10% or 12% as the case may be shown under Column No. 6.
Form 7
[* * *]575
Form 8
[* * *]576
577[Form 9
Application for review filed under sub-section (1) of Section 7-B of the Employees' Provident Funds and Miscellaneous Provisions Act, 1952
(Paragraph 79-A)
| For use in Commissioner's Office Date of filing or Date of receipt by post Registration |
|
| Signature for Commissioner |
1. Name of the Applicant
2. Designation of the applicant or his relationship with the factory/establishment (Whether Owner/Partner/Director/Manager, etc. to be indicated.)
3. Name and complete address of the factory/establishment
4. Address of the employer for service of notice/summons
5. Particulars of the order against which the review application is filed:
(i) Order No.
(ii) Date of order
(iii) Passed by
(iv) Subject in brief
6. Main ground(s) on which the application for review has been made and the relief(s) sought. (If necessary, attach a duly signed statement with copies of the documents relied upon marked as A-1, A-2, A-3 and so on.)
VERIFICATION
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (name of the applicant), S/o, D/o, W/o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . age . . . . . . . . . . . . working as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . resident of . . . . . . . . . . . . . . . . . . . . . . . . . . . do hereby verify that the contents of particulars given at Sl. Nos. 1 to 6 above are true to the best of my knowledge and belief and I have not suppressed any material fact, I further declare that:
(i) I am filing the application within 45 days from the date of the original order.
(ii) I have not preferred any appeal against the original order under the Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
(iii) I am filing with this application, the original document authorising me to represent the aggrieved person (applicable only in cases where the application is filed by agent, advocate or other representative).
| Place and date: |
Signature.] |
Form 10
578[* * *]
Form 11
579[* * *]
Form 12 (Revised)
(Paragraph 38(2) of the Employees' Provident Funds Scheme, 1952)
Statement of Contribution for the month of . . . . . . . . 20 . . . . . . . .
Wage Period From . . . . . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name and address of the establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Code No. of the Establishment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Sl. No. |
Account 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 |
Re-marks |
| |
|
|
|
EPF |
FPF1 1/6% |
Total |
EPF |
FPF1 1/6% |
Total |
|
| |
|
|
|
(a) |
(b) |
(c) |
(a) |
(b) |
(c) |
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
|
|
|
|
|
Total amount of contributions including refund of advances . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Administrative charges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total amount deposited in (i) Account No. 1 Rs. . . . . . . . . . . . . .
(ii) Account No. 10 Rs. . . . . . . . . . . . .
Bank in which deposited. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No. and date of Bank Draft/Cheque Reserve Bank of India . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Dated . . . . . . . . . . . . 20 . . . |
Signature of the Employer or other Authorised Officer Stamp of the Establishment |
N.B. (1) The names of existing members should be shown in the list of each month in the consecutive serial order of the account numbers. New members whose names are shown in this return for the first time should be shown at the end with a heading NEW MEMBERS . In the case of members transferred from another factory/establishment the name of the factory/establishment from which transferred should be given in the Remarks column.
(2) Mention should be made in Column No. 8 above, about member's rate of voluntary contribution.
(3) Variation in wages/contribution with that of previous month should be explained suitably in the Remarks column.
(For Unexempted Establishments only)
Form 12-A (Revised)
(Paragraph 38(2) Proviso of the Employees' Provident Funds Scheme, 1952)
Statement of Contribution for the month of . . . . . . . . . . . 20. . . . . . .
Name and address of the establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Code No. of the Establishment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Total No. of sub-scribers |
Wages on which contri-butions are recovered |
Amount of contributions due as per recoveries made in the wages/acquittance register |
| Worker's Share |
Employer's Share |
| EPF |
FPF 11/6% |
Total |
EPF |
FPF 11/6% |
Total |
| |
|
(a) |
(b) |
(c) |
(a) |
(b) |
(c) |
| 1 |
2 |
|
3 |
|
|
4 |
|
| |
|
|
|
|
|
|
|
| Amount of contributions remitted in Account Nos. 1 and 10 |
| |
Worker's Share |
Employer's Share |
|
| |
EPF |
FPF1 1/6% |
Total |
EPF |
FPF1 1/6% |
Total |
Total |
| |
(a) |
(b) |
(c) |
(a) |
(b) |
(c) |
|
| 5 |
|
6 |
|
|
7 |
|
8 |
| |
|
|
|
|
|
|
|
1. Total amount remitted in Account No. 1 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 Adm. Charges remitted in A/c No. 2 |
Date of remittance |
| 9 |
10 |
11 |
| 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 |
| 12 |
13 |
14 |
| Account No. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Account No. 10 . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . |
| Account No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . |
No. as per last month's return
(+) No. of New Subscribers vide Form 5
( ) No. of Subscribers left service vide Form 10
*Net Total
This should tally with the figure given at the top
right hand corner of this Form
Total No. of Employees. . . . . . . . . . . . . . . . . . . .
ContractRestTotal
Total No. of Subscribers . . . . . . . . . . . . . . . . . . .
Currency period from 1st April, 20.
to 31st March, 20.
Statutory Rate of Contribution. . . . . . . . . . . . . .
No. of members voluntarily contributing at higher than the statutory rate . . . . . .
Signature of the Employer
(with official seal)
Date . . . . . . . . . .
Notes. (1) If there is any substantial variation between the wages and amount of contribution shown above and those shown in the last month's return suitable explanation should be given in the Remarks column.
(2) If any arrears of contributions or damages are included in the figures under Columns 6 to 8, suitable details indicating the circumstances, amount, No. of subscribers and the period involved should be furnished in the Remarks column or on the reverse.
(3) Remittance shall invariably be made by deposits in the State Bank of India or its subsidiaries.
Form 13 (Revised)
For Office use only
Date Seal/Reg. No. . . . . . . . . . .
(Para 57 of the Employees' Provident Funds Scheme, 1952)
Application for transfer of EPF Account
Note: (i) To be submitted by the member to the present employer for onward transmission to the Commissioner, EPF by whom the transfer is to be effected.
(ii) In case the P.F. transfer is due from the P.F. Trust of an exempted establishment the Application should be sent direct by the employer to the P.F. Trust of the exempted establishment, with a copy to the RPFC concerned for details of the Family Pension membership.
| To, |
To, |
| The Commissioner |
M/s . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Employees' Provident Fund, |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
(To be filled in, if Note (ii) above is applicable) |
| . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
Sir,
I request that my Provident Fund balance along with the Membership details in Family Pension Fund may please be transferred to present account under intimation to me. Necessary particulars are furnished below:
| 1. Name: |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 2. Father's/Husband's name in the case of female: |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 3. Name and Address of the ex-employer: |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 4. E.P.F. A/c No. allotted by ex-employer: |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 5. With whom P.F. A/c of the ex-employer is maintained: |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . with Regional ProvidentWith Provident Fund Fund CommissionerTrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 6. Previous A/c No. allotted by the employer (if allotted separately): |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 7. Date of leaving service with previous employer: |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 8. Date of joining the present employer: |
Signature/Left Hand Thumb impression of the Member. |
Date:
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: |
|
| Being an unexempted establishment |
(i) By Regional Office at . . . . . . . . . . . . . . . . . . . |
| |
(station) |
| |
(ii) Sub-Regional Office at . . . . . . . . . . . . . . . . . . |
| |
(iii) By exempted PF Trust, viz. . . . . . . . .. . . . . . . |
| Being an exempted establishment |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
(iv) By Private PF Not covered under the Act viz. |
| 13. By whom the EPF Account of the member in the present establishments kept: |
(i) PF Regional Office at . . . . . . . . . . . . . . . . . . . (ii) PF-Sub-Regional Office at . . . . . . . . . . . . . . . |
| 14. In whose favour transfer is to be effected i.e. payee's details. |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Date: |
Signature of Employer/Authorised Official with Office Seal. |
| (FOR THE USE OF P.F. OFFICE ONLY) |
A sum of Rs . . . . . . . . . . . . . . . . . . . . . . . . . (Rupees . . . . . . . . . . . . . . . . . . . . . . . . .) is authorised for transfer, vide Annexure, K (Revised) Transfer Proceeds to be sent along with Annexure K (Revised)
By D.D. to the Regional P.F. Commissioner Officer-in-charge of Sub-Regional Office . . .
By D.D. to the P.F. Trust of the establishment with reference to details in Serial No. 14 above
Membership details under Family Pension Fund forwarded to P.F. Regional Office/Sub-Regional Office at . . . . . . . . . .
By transfer entries to the Member's Ledger Card bearing Number . . . . . . . . . . . . . . . in the present establishment from the Ledger Card bearing Number . . . . . . . . . . . . of the previous establishment . . . . . . . . . . . . .
Transfer intimation/copy of Annexure K (Revised) to the member placed below.
| P.I. No. |
CLERK |
S.S./A.A.O./A.P.F.C. |
| Scroll No. |
|
|
| Paid by Cheque No. . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . |
| Cashier/Clerk |
S.S |
A.P.F.C. |
Form 13-A (Revised)
THE EMPLOYEES PROVIDENT FUND SCHEME, 1952
(Para 57)
Application for Inter-Regional transfer of accounts to be submitted through the present employer
To
The Commissioner,
Employees' Provident Fund
..
Sir,
I request that the Provident Fund and Family Pension Account may please be Transferred to my present account under intimation to me. Necessary particulars regarding Provident Fund and Family Pension Fund are furnished below:
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 member
Endorsement to be completed by the forwarding authority
Forwarded 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 officer
of 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 14
(Paragraph 62 of the Employees' Provident Funds Scheme, 1952)
Application for Financing a Life Insurance Policy out of the Provident Fund Account
To
The Commissioner,
Employees' Provident Fund,
. . . . . . . . . . . . . . . . . . . .
I . . . . . . . . . . . . . . . . . . . . . . . son/daughter/wife/of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name in block capitals)
an employee of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . authorise
(Name of the establishment)
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 payment;
(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 of 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 Para I(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 the 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 is 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. & 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 policies).
(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 member |
Certified that this form has been *signed/thumb impressed before me by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name of member)
Account No. . . . . . . . employed . . . . . . . . . . . . .
(Name of establishment).
| |
Signature of the employer or his authorised official |
| Date . . . . . . . . . |
Designation. . . . . . . . . . . . . Code No. of the Estt. . . . . . . Name and address of the establishment and its stamp. |
*Delete portion if 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:
| Average of yearly contribution (Employees' share only) on the basis of recent 12 months Form No. 12 |
Total contributions (Employees' share only) as on |
Whether any other L.I.P. Advance has been granted before, if so, mention the date of the withdrawal |
Whether the subscriber has contributed for two years |
| |
|
|
|
The above case has been examined vide Paras 62 to 64 of the Employees' Provident Funds Scheme, 1952. A sum of Rs. . . . . . (Rupees. . . . . . .) may be paid.
| Clerk |
Head Clerk |
Accounts Officer |
R.P.F.C. |
Insurance Section
D.P. Sheet prepared and put up for signature
| Clerk (Ins.) |
Head Clerk (Ins.) |
Accounts Officer |
R.P.F.C. |
Form 15
The Employees' Provident Funds Scheme, 1952
Form of Assignment of Policies under Paragraph 64(1) to be endorsed on Policy
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s/d/w of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby assign unto the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Board of Trustees, Employees' Provident Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . within the policy of assurance as security for payment of all sums which under Paragraphs 67(1) and 68 of the Employees' Provident Fund Scheme, I may hereafter become liable to pay to the Fund.
I herewith certify that no prior assignment of the within policy exists dated . . . . . . . . . . . . . . . this . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . day of. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Station . . . . . . . . . . . . . . . .
Account No. . . . . . . . . . . . . . . . .
*Signature or left/right hand thumb impression of the member.
Witness
Certified that this Form has been signed before me by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . employed in . . . . . . . . . . . . . . . .
Regd. No. of the Factory/Establishment
Code No. of the Factory/Establishment
Dated . . . . . . . . . . . . . . . . 20
Signature of the Employer or any Authorised Officer
Designation . . . . . . . . . . . . . . . . . . . . . . . . . .
Stamp of the Establishment.
Note. (1) The Policy is required to be assigned within six months after the first withdrawal in respect of it by endorsement thereon in terms of the above Form.
(2) While assigning the Policy the notice hereunder should be given to the Life Insurance Corporation.
NOTICE
To
The Divisional Manager,
The Life Insurance Corporation of India.
Unit . . . . . . . . . . . . . . . .
Subject: Assignment of Policy No. . . . . . . . . . . . . . . . .
Notice is hereby given that policy No. . . . . . . . . . . . . . . . . for Rs. . . . . . . . . . . . . . . . . . . . . . .
on the life of Shri/Shrimati . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . as on this . . . . . . . . . . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . 20. . . . . . . been assigned in favour of Central Board of Trustees, Employees' Provident Fund by Shri/Shrimati . . . . . . . . . . . . . .
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 Assignee
Full address
* Left hand thumb impression in the case of illiterate male member and right hand thumb impression in the case of female member.
Form 16
The Employees' Provident Funds Scheme, 1952
Application for advance from the Fund under Paragraph 68-B
PART 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 member. |
| |
Postal address: |
* Delete terms if not applicable
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:
*(i) Original title deed.
*(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-agricultural 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/establishment
Regd. No. of the factory/Establishment
Designation of the signing official with
stamp of the factory/establishment
Code No. of the factory/Establishment
*Delete items if not applicable.
**Left hand thumb impression in the case of illiterate male member and right hand thumb impression by illiterate female member.
Payment authorised No. . . . . . . . . . . . . . . AuditorH.C.A.-O.
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 may be.
(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.
Form 17 & 18
[Not printed]
Form 19
(Paragraph 72(5) of Employees' Provident Funds Scheme, 1952)
Form to be used by a Major Member of Employees' Provident Funds Scheme, 1952 for Claiming the Employees' Provident Fund Dues:
( Refer to Instructions )
1. Name of the member (in Block Letters)
2. Father's Name (or husband's name in the case of married woman)
3. Name and address of the Factory/Establishment in which the member was last employed
4. Account No.
5. Date of leaving service
6. Reason for leaving service
| 7. Full Postal Address [in Block Letters] |
Shri/Smt./Kumari S/o/W/o Pin |
| 8. Mode of Remittance (a) by postal money order at my cost (b) by account payee cheque sent direct to credit to my S.B.A/c (Scheduled Bank/P.O.) under intimation to me. |
Put a tick in the box against the one opted [ ] [ ] to the address given against item No. 7 [ ] S.B. A/c No. in figure . . . . . . . . . . . . . . . . in words . . . . . . . . . . . . . . . . Name of the Bank Branch Full address |
| (Advance Stamped Receipt furnished below) of the Branch |
Certified that the particulars are true to the best of my knowledge
Date of Joining the Establishment . . . . . . . . . . . . . . . . . . . . . . . . .
Date of Leaving Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contribution for the current financial year
| Month |
. . . . . . . . . Contribution . . . . . . |
Period of break, if any |
Month |
. . . . . . . . Contribution . . . . . . |
Period of break, if any |
| |
Employee |
Employer |
Total |
|
Employer |
Employer |
Total |
| |
EPF |
FP |
EPF |
FP |
EPF |
FP |
|
EPF |
FP |
EPF |
FP |
EPF |
FP |
| |
|
|
| |
|
|
(Information to be furnished by the employer if the claim form attested by the employer)
Certified that the above contributions have been included in the regular monthly remittance.
The applicant has signed/thumb impressed before me.
| . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signature of the employer or authorised official |
. . . . . . . . . . . . . . . . . . . . . Signature of left/right hand thumb impression of the member |
Date . . . . . . . . . . . . . . . .
Designation & Seal
Encl.
Declaration of non-employment.
I declare that I have not been employed in any Factory/Establishment to which the Act applies for a continuous period of not less than 2 months immediately proceeding the date of my application for final withdrawal of my Provident Fund money.
| Date . . . . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
Signature of left/right hand thumb impression of the member |
Advance Stamped Receipt
Received a sum of Rs* . . . . . . . . . . . . . . . . . . (Rupees* . . . . . . . . . . . . . . . . . . . . . . . . .) from Regional Provident Fund Commissioner/Officer-in-Charge of Sub-Regional Office . . . . . . . . . . . deposit in my Savings Bank Account towards the settlement of Provident Fund Account.
| |
|
|
|
| |
* The space should be left blank which shall be filled in by Regional Provident Fund Commissioner/Officer-in-charge of S.R.O. |
|
Affix 1 Rupee Revenue Stamps |
Signature of left/right hand thumb impression
of the member
(For the use of Commissioner's Office)
A/c. settled in part/full entered in
F-21-A/24/2/9 Withdrawal Register.
(P.I. No.) . . . . . . . . . . . . . . . . . . . . . (M. O./Cheque) . . . . . . . . . . . . . . . . . . . . . . . . . . Account No. . . . . . . . . . . . (Section) . . . . . . . . . . . . . . Under Rs . . . . . . . . . . . . . . . . . . . . . .
[Passed for Payment of Rs . . . . . . . . . . . . in words]
| M.O. Commissioner (if any) Net Amount to be paid by M.O. . . . |
Accounts Officer Date . . . . . . . . . . . . . . . . . |
(For use in Cash Section)
Paid by inclusion in Cheque No. . . . . . . . . . . . . . . . . . . . . . . . dt . . . . . . . . . . . . . . . . . . Vide Cash Book (Bank) Account No. 10 Debit Item No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Remarks |
|
|
| ACKNOWLEDGMENT CARD |
| Account No. |
EPFO |
Office of the RPFC/Officer-in Charge |
ACKNOWLEDGEMENT
| Received the following claims: |
Registration No. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| EPF |
Date Official Seal . . . . . . . . . . . . . . . . . . . . . . . . |
| FPF |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| IF |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 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. |
POSTCARD |
Postage Prepaid |
| |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
EMPLOYEES' PROVIDENT FUND ORGANISATION
Office of the Regional Provident Fund Commissioner/S. R.O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Full Address) . . . . . . . . . . . . . . . . . . . . . . . .
Instructions for filling up the applications (Forms 19 & 10-B)
(For the guidance of applicant only. Not to be sent along with the claims)
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 and 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 seperate challan and receipted triplicate challan should be enclosed to the claim.
11. In support of claim under Employees' Family Pension Scheme, 71 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 proferred S. Nos 2, 6 & 8 are not applicable.
Form 20
Employees' Provident Funds Scheme, 1952
(For claiming the Provident Fund accumulation of minor/deceased member)
Regn. 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 of 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. |
|
| (d) Account No. |
|
| (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 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) Father's/Husband's Name
(c) Sex
(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 member.
| *3. |
To be filled by the Guardian/Manager of Minor/Lunatic Member or Lunatic Minor |
.png) |
Nominee[s]/Legal Heir[s]/Family member[s] |
.png) |
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. Particulars of the minor/Lunatics Nominee(s)/Legal Heir(s)/Family Member(s) on whose behalf the Provident Fund Amount claimed.
| Sl. No. |
|
|
|
|
Relationship |
| |
Name |
Sex |
Age |
Religion |
with the member |
with the guardian |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 1 2 3 4 |
|
|
|
|
|
|
| * Delete, if not applicable |
|
|
| 4. |
Claimant's Full Postal Address (in Block Letters) |
Shri/Smt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 No. 4 |
| or |
(b) by account payee cheque sent direct for credit to my S.B. A/c. (Sch. Bank/Post Office) under intimation to me (Advance Stamped Receipt) furnished below: |
|
*S.B. Account No. . . . . . . . . . . . . . . . . . . . . . . . Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full address of Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . |
Certificate
*To the best of my knowledge no posthumous child will be born to the 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 myself and the Provident Fund money claimed on behalf of minor/lunatic will be spent in his/her best interests and benefit.
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 6 months immediately preceding the date of the application.
Enclosure
Signature of left/right hand thumb
impression of the claimant
Date
Delete if not applicable.
Advance Stamped Receipt
[To be furnished only in case of 5(b) above]
Received a sum of Rs . . . . . . . . . . . . [Rupees . . . . . . . . . . .] from Regional Provident Fund Commissioner/Officer-in-Charge of Sub-Regional Office . . . . . . . . . . . . . . by deposit in my Saving Bank Account towards the settlement of Provident Fund Account of Shri/Smt. . . . . . . . . . . . . . . .
| *The space should be left blank which shall be filled in by RPFC/Office-in-Charge of S.R.O., |
Affix 1 Rupee Revenue Stamp |
Signature of left/right hand thumb
impression of the claimant
Certificate of the attesting authority
Contribution for the current period.
| 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 |
| |
|
|
| |
|
|
| Certified that the above contributions have been included in the regular monthly remittances. |
Certified that the facts stated above are correct.
Certified that the claimant Shri/Smt./Kumari . . . . . . . . . . . . . . . . . . . . . . . . . . . . . is known to me and has signed/thumb impressed before me.
Signature of the employer or authorised officer
Designation & Office Seal
| For the use of Commissioner's Office Account settled entered in Form 21-A/24/2/9 (Revised) & Withdrawal Register. |
| Clerk |
Head Clerk |
| Under Rupees . . . . . . . . |
P.I. No. . . . . . . . . . . . . . . . . . . . M.O./Cheque |
Account No. . . . . . . . . |
| Section . . . . . . . . . . . . . . |
|
| Passed for Payment Rs . . . . . . . . . . . . . . . . . . |
| (in words) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| M.O. Commission (if any) Net amount to be paid by M.O. |
Accounts Officer Date |
| |
|
| For use in Cash Section Paid by inclusion in Cheque No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vide Cash Book (Bank) Account No. 3 Debit Item No. . . . . . . . . . . . . . . . . . . |
| Head Clerk |
Assistant Commissioner/Regional Commissioner |
| Remarks |
|
|
| ACKNOWLEDGMENT CARD |
| Account No. |
EPFO |
Office of the RPFC/Officer-in Charge of Sub-Regional Office |
ACKNOWLEDGEMENT
| Received the following claims: |
Registration No. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| EPF |
Date Official Seal . . . . . . . . . . . . . . . . . . . . . . . . |
| FPF |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| IF |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
POSTCARD |
Postage Prepaid |
| 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. |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
EMPLOYEES' PROVIDENT FUND ORGANISATION
Office of the Regional Provident Fund Commissioner/S.R.O. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Full Address) . . . . . . . . . . . . . . . . . . . . . . . .
Instructions
(For the Guidance of applicant only, not to be sent along with the claim)
The following instruction should be carefully read before completing the form:
1. Employees' Provident Fund Scheme, 1952: Form 20: Claim for the withdrawal of Provident Fund Accumulation of minor/deceased member.
2. If the member is a minor by the guardian.
OR
On 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 5000 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 on Estate Duty Clearance Certificate.
Form 11 (FPF): Claim for benefits as admissible under the Employee's 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
(a) the widow or widower.
(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 1000 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 5000 (if amount receivable under Employees' Provident Fund and Employees' Deposit-Linked Insurance does not exceed 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 E.P.F.; (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 requisites 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 only
Dated Official Seal and Registration No. . . . . . . . . . . . . . . . . . . . .
Forms 21-30
[Not printed]
Form 31
Application for Advance from the Fund
[Refer: INSTRUCTIONS]
| Purpose for which advance is required |
Amount of advance required Rs 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.U.P./
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Full address)
(d) By money order at my cost to the address given against Sl. No. 6 . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
*I declare 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 & I will abide by the condition governing the grant of advance under the scheme. Certificate/documents 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 in by the E.P.F. office. |
| |
Signature of member |
Affix 1 Rupee Revenue Stamp |
| (TO BE FURNISHED BY THE EMPLOYER) |
| [During the closure/lockout of the Factory/Establishment by any gazetted officer or the Chief executive/Head of local authority or MP or MLA or member of C.B.T./Regional Committee, EPF.] |
| Certified that the application has been signed by the member in my presence after he/she has read the contents and have been explained to him/her by me and that the information given in the application is correct. Required certificate(s) is/are enclosed. |
| Date . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . |
| Designation of the signing officer with |
Signature of the Employer or an Authorised Officer |
| Stamp of the Factory/Establishment |
of the Factory/Establishment |
| Encl. . . . . . . . . . . . . . . . . . |
|
| Under Rupees . . . . . . . . |
|
|
| For use in Provident Fund Commissioner's Office |
Section . . . . . . . . . |
| |
Account No. . . . . . |
| AUTHORITY FOR PAYMENT OF ADVANCE UNDER PARA 68 Passed for Payment for Rs . . . . . . . . . . . . . . (Rupees . . . . . . . . . . . . . . . . . . . . . . only) Mode of remittance: Refer Sl. No. 7 M.O. Commissioner if any, Net Amount to be paid by M.O. |
| Clerk P.I. No. |
Head Clerk Vide Payment scroll P.C. to A.O. |
Account Officer |
| For use in Cash Section |
| Paid by inclusion in Cheque No. . . . . . . . . . . . . . . . . . . Dated the . . . . . . . . . . . . . . . . . . . . . . . vide Cash Book (Bank) Account No. 3 . . . . . . . . . . . . . . . . . . debit item No. . . . . . . . . . |
| Clerk |
Head Clerk |
Assistant Commissioner |
Remarks
Instructions
A member of the fund may avail the following non-refundable in advances.
The documents to be furnished in support of the application are given in brackets.
1. Purchase of a Dwelling site: (From on 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 on 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/flat 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, Approved Plan 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, a certificate, from the appropriate authority specifying the date of completion of the house).
5. Repayment of (Housing Loan to State Govt. Housing Board, Municipal Corporation or a Body similar to Delhi Devp. Authority: (A Certificate from the lending authority furnishing the details of loan and outstanding amount.)
6. Closure/Lockout of the Factory & Establishment, for reasons other than Strike: (Furnished 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)
Note: (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 such Regional Office through the establishment.
CERTIFICATE-A (Refer: Instruction Sl. No. 6)
Certified that no compensation was paid to the member Sri/Smt/. . . . . . . . . . . . . . . . . . . . . for the period of lockout/closure.
(Signature of the employer/authorised official with date and seal)
CERTIFICATE-B (Refer: Instruction Sl. 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 seal)
CERTIFICATE-C (Refer: Instruction 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 seal)
Medical 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 specialist 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.
| Delete if not applicable |
(Signature of Doctor with dated seal) |
CERTIFICATE-D (Refer: Instructions Sl. No. 11)
Certified that the movable/immovable property of Shri . . . . . . . . . . . . . . . . . . . . . . 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 with seal
and Member or C.B.T./Regional Committee with seal and date)
CERTIFICATE-E (Refer: Instructions Sl. No. 12)
Certificate 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 seal)
CERTIFICATE-F (Refer: Instructions Sl. No. 13)
Certificate that Shri/Smt/Km./. . . . . . . . . . . S/o/W/o/D/o . . . . . . . . . . . is physically handicapped viz. . . . . . . . . . . . and requires equipment.
(name of handicap)
viz. . . . . . . . . . . . costing about Rs . . . . . . . . . . . to minimise the hardship on account of handicap.
(Signature of the Doctor with date and seal)