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/ Mobile Number
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FORM5IF
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THE EMPLOYEES'
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1978
DEPOSIT- LINKED INSURANCE SCHEME, 1976
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To be filled up separately by each claimant. In case the claimant is minor
it should be filled up by the guardian on hislher behalf. Where there are more than one minor the guardian should
claim in one Form on their behalf.
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form
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,Note - Read the "Instructions" carefully before completing this
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The Particulars in respect of the deceased member
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(a) Name ofthe Deceased member
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(b) Father's Name (Husband's name in the case of married woman)
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(c) Date of Death (ddlmmlyyyy)
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11
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(d) Name and Address of the Factory !Establishment
where the member was last employed.
at./<IiT.
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(e) Provident Fund Account No
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2.
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RO/Office Code
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Estt. Code No.
NcNo.
fcm1Jr/ Details of the claimant/guardian.
t;) OfJ1!"/Name
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(tr) ~
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Date of Birth (ddlmrnlyyyy)
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Relation with the deceased
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fcm"uJ Ifth e calmant
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'Ill{/Name of the minor
1 fth e mmor nomine eIh eir
a guar dran, detalso
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~/Relationship
ofthe
guardian with minor
IS
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Claimant's Full Postal address (in block letters)
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Dol S/o W/O Hlo
..................................
~ ~/Signature
Form 5IF
of claimant
([Link])
JiR/Pin
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of Employer
Page 1 of4
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Mode of remittance:
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if anmrr <lIT<IT ~"4;m
\iJT1?/ By account payees cheque! electronic mode
sent Direct for credit to my S.B. NC (Scheduled
Bank IPO) Under intimation to me
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S.B Account no
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Name of the Bank
WRlIT/Branch
ill\" Please attach a copy of
cancelled/blank
WRlIT
q;J
Cheque)
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mrr/ Full Address of the Branch
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(Signature or Left/Right hand thumb impression of the claimant)
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Advance Stamped Receipt
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.........................................................................................
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*Received a sum ofRs
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('Rupees
from Regional Provident Fund Commissioner/Officer-in-charge
only)
of sub Regional Office
by
deposit in my Saving Bank account towards the Employees' Deposit Linked Insurance benefit.
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*The space should be left blank which shall be filled in
by Regional Provident Fund Commissioner/Officer
incharge ofS.R.O.
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Revenue
Stamp
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Signature or LeftlRight hand thumb impression of the claimant
Form 5IF
([Link])
Page 2 of4
Certificate
To be furnished by the Employer)
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Certifiedthat the claimant is has signed/thumb impressedbefore me. I declare that the above particulars are true to the best of
my knowledge.
2. ~fcl;mWffi~fcl;~q\)~~~~~q;f
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Certified that the member died on
while in service.
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Certified that the Provident Fund accumulation of deceased employee, late Sh/Smt./Kumari
.
..................................................... Ale. No
were paid to ShrilSmt./Kumari
(i)
(ii)
(iii)
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(The employer of exempted Establishment shall send on attested copy of the nomination of the deceased employee)
q\) ~ if; ~
~ 12 ~
it ~
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ri -.'j it'! f<t<R"I !Balance in Provident Fund at
the end of the month, proceeding the 12 months immediately proceeding the death of the member
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1952" W mll ~
am 'ffi \iIf\//To be filled in by employee of establishment exempted under
EPF Scheme 1952.
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1lrn"/ Month
'Il"'Rfi / Refund
Interest
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Both
Withdrawals
Progressive
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Balance
of withdrawal
shares of
Contribution
l.
2.
3.
4.
5.
6.
7.
8.
9.
10.
ll.
12.
~/Total
12 lIM q;r iiI'R?
Total of l2 Months
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Provident Fund Balance f
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Average Balance ~
~ ~
.
.
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Signature of the employer (Name & designation with official Seal)
~Date
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Delete, if not applicable
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Note: The employer of un-exempted establishment should fill in the column 2 only and the employer of exempted
establishment should fill in the all columns.
Form 5IF
([Link])
Page 3 of4
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(For the use of Commissioner's Office)
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Entered in Form 21-N9 (Revised) 1 I.F. withdrawal Register
q;fl\ 21-11/9 ~)
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SSA
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(Under r
"T"fR >!G
P.!' No
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AccountNo
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Section
........................................................
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Passed for payment for ~
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) and the
amount may be remitted for credit to the Saving Bank Account No
[Link]
in respect of
maintained at
(Bank)
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Paid by inclusion in cheque No.
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SSA
Form 5IF ([Link] )
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<Cl\jffI;[ Wf1I;
Accounts Officer
Date:
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Page 4 of4
