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Amandeep Ji CCF Form

The document is a Composite Claim Form for Death Cases from the Employees' Provident Fund Organisation, detailing the necessary information for claiming Provident Fund, Pension, and Insurance benefits following the death of a member, Mr. Amandeep Singh Chouhan. It includes personal details of the deceased and claimants, their bank account information for fund disbursement, and required enclosures such as the death certificate. The form must be certified for accuracy by the claimant and employer.

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107 views3 pages

Amandeep Ji CCF Form

The document is a Composite Claim Form for Death Cases from the Employees' Provident Fund Organisation, detailing the necessary information for claiming Provident Fund, Pension, and Insurance benefits following the death of a member, Mr. Amandeep Singh Chouhan. It includes personal details of the deceased and claimants, their bank account information for fund disbursement, and required enclosures such as the death certificate. The form must be certified for accuracy by the claimant and employer.

Uploaded by

solargrew
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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www.epfindia.gov.

in
EMPLOYEES’ PROVIDENT FUND ORGANISATION मममममम
Composite Claim Form in Death Cases म . Mobile No. 9829166247
[Form-20(PFPayment)/Form-10-D(Pension)/Form-5IF(EDLI)]

Tick whichever is/are applicable Provident Fund(√) Pension (√) Insurance EDLI] (√)
1
Type of Pension claim: DEATH CLAIM
Name of the deceased member (in CAPITAL letters) Mr. Amandeep Singh Chouhan
2
(a/Father’s Name : (A) Bharat Singh
3
(b/Spouse’s Name:
Marital status of deceased member UNMARRIED
4

a) Aadhar Number of the deceased member (if available) 691997322158

5 bUniversal Account Number (UAN) 101789380591


c) PF AccountNumber (in case UAN not available) GJAHD25911150000010854

6 Date of Leavingservice 08.02.2025


a)WhetherSchemeCertificatehasbeenissued(Yes/No) NO

b)If Yes, Number of Scheme Certificate NO


7

-
c)Scheme Certificate issuing office

Period ofNon-Contributory
8
service (Year/Month/Days) – (To be filled by the employer)
9 Date ofdeath of the member 08.02.2025
Whether the member had died while in service(Yes / No) YES
10

CLAIMANT’SDETAILSFORPROVIDENTFUND,PENSIONANDINSURANCE(EDLI)
*Particulars of the claimant/minor/nominee(s)/legal heir(s)/surviving family member on whose behalf the claim is submitted
* In case of more than five family members, the details of family members may be furnished in a separate sheet, duly attested by the em ployer.

Marital Relationship with


/Father’s / Date of
S.N.S /Aadhar Number Gender Status Member Guardian
11 Name Spouse’s Birth
Name
i Bharat Singh Kishan Singh 929086486637 Male 01-01-1976 MARRIED Father
2 Santosh Devi Bharat Singh 877743083964 Female 01-01-1978 MARRIED Mother

BankAccount detailsfor payment of PF &EDLI:


Bank Account details Claimant – I Claima Claima Claima
for payment nt –II nt –III nt –IV

12
Name Bharat Singh Santosh Devi
Saving Bank Account 34345158906 34345159228
No.
Name & address of the Beawar ( Evening Branch ) -Pali Bazar , Ajmer -305901 Beawar ( Evening Branch ) -Pali
Bank Bazar , Ajmer -305901

IFS Code of Bank SBIN0004668 SBIN0004668

BANKACCOUNTDETAILS FOR PENSION


Bank Account details for payment Claimant – I Claimant –II Claimant –III Claimant – IV

Name Bharat Singh Santosh Devi

13 Saving Bank Account No. 34345158906 34345159228

Name & address of the Bank Beawar ( Evening Branch ) -Pali Bazar , Beawar ( Evening Branch ) -Pali
Ajmer -305901 Bazar , Ajmer -305901

IFS Code of Bank SBIN0004668 SBIN0004668

Full Postal address of claimant


14 Village -Singhadiya ,post Nundrimandev ,Tesh. Beawar , Dist. Ajmer (Raj)-305901
Pin:- 305901

Certified that the particulars are true to the best of my knowledge.

Claimant’s signature Employer’s Signature

Name…Bharat Singh & Santosh Devi


Designation & Seal of Employer
Enclosures )i Death Certificate
i) Joint photograph of all the
claimants
i) Date of Birth certificate of
children claiming pension
For verification of a copy of bank accounts cancelled cheque or attested copy of first page of bank Pass Book.

Name of attesting Authority Official Seal:

Signature of the applicant /Left


hand Thumb Impression

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