Canada/India Agreement

Version (2019-12-04)

Applying for an Indian Provident Fund under the Employees’ Provident Fund Scheme

Here is some important information you need to consider when completing your application for Indian benefits.

If you, or your deceased family member, contributed to the Employees’ Provident Fund Scheme (EPF) and did not receive a lump sum payment of contributions upon cessation of Indian employment, this Agreement may help you obtain the payment while residing in Canada. Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of a witness is required. Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application. Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you. You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy: Accountant; Chief of First Nations Band; Commissioner for Oaths; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Naturopathic Doctor, Nurse Practitioner, Ophthalmologist, Optometrist, Pharmacist, Psychologist, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a reciprocal Social Security Agreement; Police Officer; Professional Engineer; Social Worker; Teacher, University Professor. People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document. They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way. If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you. Return your completed application, forms and supporting documents to:

International Operations Service Canada PO Box 2710 Station Main Edmonton, Alberta T5J 2G4 CANADA

Disclaimer:

This application form has been developed by external sources in cooperation with Employment and Social Development Canada. The content and language contained in the form respond to the legislative needs of those external sources.

~ ~./Mobile Number

~ ~ .q ~ ~ fm)- / For Office use only GTCIT~/Clam I.D.

~~-f.'tfil"~.1952EMPLOYEES' PROVINDENT FUND SCHEME. 1952

U"q"'jf-19/ Form -19<!6 'IiT'f ~ f.'tfil"<PT GTCITq;ffl Wf!I ~ ~ f.'tfil"~ ~ ~ ~ srn 'Iffi \ifJ11"

From to be used by major member of the Employees' Provident Fund Scheme, 1952 for claiming theProvident Fund dues [Para72] (5)]

"!I'I"'lI ~ "ft l!@ ~ q;)- ~ I (Read the instructions before filing up this for

~.~.,*.m / IFS Code .

W<YTq;r ~ lfffi" / Full Address of the Branch .

1. ~ <PT 'fIif ~ 31~. ~Name of the member(in block letters).

2. ~/tM <PT"'W! ~ ~ ~ 1fl"'ffi Ti}Father's! husband's Name in the case of marriedwomen

3. ~!~ <PT "'W! er lfffi" IuffiI1 ~ ~iIR ~ ~ lflIT I!If /Name and Address ofthe Factory !Establishment in which the memberwas last employed.

4. Wffi" ~./ Account No.

5. ~ ~ qlt ~lDate ofleaving Service

6. ~ ~ <PT ~ /Reason of leaving Service

7. lP.i ~ <PT '!'T lfffi"I--- Full postal address (in block letters)

~/~/~/ ShrilSmt.lKumari .

W/~/~/ S/ofW/o/D/o .

....................................................................... Pin No./~ m .

"i'itttffl flI;"m ~ <Rtql" lR ~ "I 101> <'f1ll1i

Put a 'Tick' in Box against the one opted8. "T"fR qlt ~ / Mode of Remittance

(ci» ~ ~ lR ""*~ srn/ (a) By Postal MoneyOder at my cost.(~) ~ ~ q;ffl ~ ~ ~ Wffi" ~.(~~ /~) ~ ~ -.hi; "~iIl;'1f.'1q> ~ <f 3ITGRIT

Wffi" ~ >lvrr \ifJ11"/ (b) Byaccount payees chequeelectronic mode sent Direct for credit to my S.B.A/e(Scheduled Bank/P.O.) Under intimation to me.(<II1R W um 1t; lmtt/~ __ 11ft" 'qlIj lIftt~ 1ftPlease attach a copy of cancelled/blank Cheque)

1lG ~. 7 .q ~ 1TI1tffllR / To the address given against item No.7

~ tq; Wffi" ~.I S.B Account no .

tq; <PT"'W!/ Name of the Bank .

W<YT/ Branch

(3iIWf ~ wit "ffirG ~ eft ~~) (Advance Stamped Receipt furnished below)~ ~ \lIffiT ~ ~ ~ "'l"f ~ ~ ~ ~ fcmur "ffift ~ / Certified that the particulars are true to the best of my knowledge.

<OntRT it ~ ql't ~ I Date of Joining the Establishment ..

\if"! ~/Date of Birth .

Tffi'! fcffli'flf <PT ~/ Contribution for the current Financial Year (i'fIf 2012-13 0!T'l 'lill)(Not applicable from 2012-13)- atmR ~;m3Fl1U"1Ita.~ sr er 'fi!RT atmR ~,,:t~=~mmMonth Contribution Period of Break ifany Month Contribution Period of Break ifany

'Nf<i. """""f.1llllftIT ~ ~ """"" EM=ERS

'!j<Itt EMPLOYEE EMPLOYERS TOTAL Wag EMPLOYEE TOTAL

il Wa "'.'1. 'l!t "'.'1. 'l.q. "'.'1. 'l.q. il es "'.'1. 'l.q. "'.'I.to'!. '1.11. "'.'I.f.!. 'l.q.ges f.!. FP f.!. FP f.!. FP f.!. FP EPF FP EPF FP

EPF EPF EPF EPF1fT"il March ~September• April ~October~May 'IO"R November"l.'l June ~December~July ~ January_~t q;ffi) FellrlJary

# ~ ~ ~/Member's Signature

Form 19 (www.epfindia.gov.in)# ~ ~ ~ !Employ's Signature

Page lof2

Member's CanadianSocial Insurance Number: _____________________________

~Gf1IT"\TCI"'3I~am~1'iPln7["llftm~~~am~\iIl'1l")(Information to be furnished by the Employer if the Claim Form is Attested by the Employer)

~ 1'iPlni1ITffTt 1$ ~ amGR f.I<lf'4o~ \Jfl'fT "1"1 -.lfu lj mfiffi t 1/ Certified that the above contributions have been included inthe regular monthly remittances.

mff" ~ m<R ~ f<l;s'/3Mor wrrm tiThe Applicant has signed/thumb impressed before me.

~ if; ~/ Signature of Employer~lDate .~ <liT'IG-WI 3l'R ~Designation & Seal of Employer~/Encl.~ l'f "::j ~ ~ tl't1IvIT / Declaration of non-employment~ : Cfi."I'f.f.!I".~ 1952 if; fm 69 if; ~-fm (2) if; ~ «<) 3l'R ~-;ro (1) if; ~ «I) if; 3R'I'fcr f.'It!cR if; ~ ~ ~ if; ~ Ti Gf1IT~

~ ~ ~ ~ Gl ~ if; "iITG~ CfiVIT ~ ~ ~ WlTIlR ~ W ID 3{ercrr~ ~ Ti ~ ID Riffi lR ~ l'fl1j:, 'TIff t INote: In the case of submission ofapplication for settlement under clause (S) of sub-paragraph (i) and in clause (b) of Sub paragraph (2) of paragraph 69 of the

EPF Scheme, 1952 the claim should be submitted after two months from the date ofleaving service provided the member continues to remain un-employedin an estt. to which the Act applies.

~ if; ~ ~ "iIlli/c;nt ~ if; ~ <liTf.mRSignature or Left! Right hand thumb impression of the member

~ if; ~ 3{l':I<IT"iIlli/c;nt ~ if; ~ <liTf.mR~ /Date Signature or left! Right hand thumb impression of the member

3lftrq feq;c "Rlfi ~ (~ ~ 8«<) if; ~ Ti ~ ~ \iIJlt)

ADVANCE STAMPED RECEIPT (To be furnished only in case of8(b) above)Ml<i ~ ~ ~/wrnt ~--Rm ~ ~ 3ltR ~ ~ «Tff if; f.'It!cR lR( ~ ) ql) ~ 3ltR ifi'.IO'fq; «Tff 1) "SIT'<fql) I

Received a sum of ~ ( ~ only) from Regional Provident FundCommission/Officer-in-Charge of Sub Regional Office by deposit in my Saving Bank account towards the settlement of my

Provident fund Account.

1.00 ~ <tit ~ feq;c~Affix 1.00 ~ RevenueStamp

~~\iIfIl

The space should be left blank which shall be filled in byRegional Provident Fund Commissioner, Office-in chargeof Sub-Regional Office.

~ ~/ (For the use of Commissioner's Office)«Tff <liTf.\qcr;f 1'iPln7["llfI '!>Jlf.=i. 21-"11/2 om ~ ~/3 tr. it f.!I". JIInl 9 (mTrfmr) 1) ~ ql)Nc. Settled in Part/Full Entered in F-21-N2 and with drawal Register! Form 3 (F.P.F.) Form 9(Revised)

~ if; ~ "lIT"UI:i/c;nt ~ if; atrr.B <liTf.mRSi ature or LeftlRi t hand thumb im ression of the member

wr.~"",.SSA

3Pj.lIlf

SS

~ if; ~/ UnderRs .

'!.fRlT'f lfG" .=i.P.I- No.

WCIT.=i.Account No.

Accounts Officer~Dated

~ ar:rwr itm it ~)/ (FOR USE IN CASH SECTION)~

Paid by cheque No , Date. . Vide cash bookif; WCIT~-10 lfG" 'W! ~ am 1'iPln7["llfIand Account No. ID Debit item No.______ 3Pj.lIlJ---.LSS <1.31T./el.31TI A.C.IR.C. _

~/REMARKS

Form 19 (www.epfindia.gov.in) Page 2 of2

Claimant should write Indian Mobile Number (if any) on top of form to get SMS alerts

EMPLOYEES’ PROVIDENT FUND SCHEME 1952

FORM 19

FOR CLAIMING A FINAL SETTLEMENT FROM THE PROVIDENT FUND

AFTER RESIGNATION OR TERMINATION OF CONTRACT

(PLEASE MAKE SURE THAT YOU ARE USING THE APPROPRIATE APPLICATION FORM AND

INSTRUCTIONS DOWNLOADED FROM YOUR COUNTRY PAGE ON THE ‘INTERNATIONAL

WORKERS’ TAB ON WWW.EPFINDIA.COM OR BY VISITING THE SERVICE CANADA

WEBSITE (http://www.servicecanada.gc.ca/). INSTRUCTIONS FOR EACH COUNTRY MAY VARY)

INSTRUCTIONS

WHO CAN APPLY?

1. Members of the EPF Scheme 1952 enrolled as International Worker after leaving service

under conditions mentioned against 3 below.

a. In case of the death of the member, the family members/nominee/legal heir

should apply through Form 20.

GENERAL INSTRUCTIONS

1. Claimants who mention their Indian mobile number on the form will get SMS alerts

2. At different stages of the approval process of their claim form. Note: this service is only

available to Indian mobile holders.

Alternatively, the claimants can also visit the EPFO’s website www.epfindia.com or

www.epfindia.gov.in to view the status of their claims through the link - ‘Know Your Claim

Status’.

3. Form should be completed in BLOCK LETTERS without any cursive writing/or abbreviations

4. Against the column, “Reason for leaving service” indicate the one applicable

a) Going back to my country after resignation or completion of posting tenure

b) Any other reason (Please specify)

5. Member’s Account Number: The account number should have the Region Code (two

Alpha letters), Office Code (three Alpha letters), Establishment Code Number (Numeric up

to a maximum of seven characters), Extension (sub code, if any, Numeric up to a maximum

of three characters) and Employee Account Number (Numeric up to a maximum of seven

characters).

(a) The Region Codes have changed after creation of the multiple regions in

some states, namely Maharashtra, Tamil Nadu, Karnataka, West Bengal, Punjab,

Gujarat, Andhra Pradesh, Uttar Pradesh, Haryana and Delhi. For getting the correct

Region and Office Codes, please visit Establishment Search facility provided under link

for Employees on EPFO’s website www.epfindia.gov.in or www.epfindia.com

6. Payment shall be made by directly crediting the Bank Account mentioned by the

claimant. Persons living outside India may either indicate his/her Indian Bank Account or the

bank account maintained in his/her country. Payment to a foreign bank account is only

available in a country with which India has a social security agreement.

ATTESTATION/FORWARDING OF CLAIM FORM

In case of a worker who is leaving the Indian workforce and is planning to move abroad, the

application for a Provident Fund settlement should be submitted while he/she is still in India.

The application should be submitted through the employer with whom the member was last

employed. The employer will then forward the claim to the concerned Regional Provident Fund

Commissioner after attestation and completing other formalities. One can still apply from

Canada in case of an Indian who left for Canada and is applying from Canada.

In case an outgoing “International Worker” that is, a worker who has left the Indian

workforce and resides outside of India, the application form for a Provident Fund settlement

should be completed by the applicant and forwarded to International Operations, Service

Canada, the Canadian liaison agency where your application form will be reviewed and

forwarded to EPFO together with any necessary information for further action.

In case the claimant is using a downloaded version of the form then all pages should be

signed by the claimant.

In case of a closed establishment whose Authorised Signatory/Employer is not available, the

claimants may forward the claim to the EPFO with banking details (example, void cheque or

portion of bank statement which includes the name and address of the account holder and the

complete account number).

DOCUMENTS TO BE ENCLOSED

A copy of the blank/void cheque having the account number and IFS/SWIFT Code or copy of front page of the bank statement including the complete bank account details and address of the claimants should be enclosed with claim form. International Worker’ means Any 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 social security programme of that country, by virtue of the eligibility gained or going to gain, under the said agreement; An employee other than an Indian employee, holding other than an Indian Passport, working without a valid detachment certificate, for an establishment in India to which the EPF & MP Act, 1952 applies

COLUMN WISE INSTRUCTIONS CORRESPONDING WITH SERIAL NUMBERS ON FORM

1. Write full name

2. Same as above

3. Write full name of the establishment and its Indian address

4. Write full account number including region code, office code, establishment code and member account number

5. Write here the last effective date upto which salary and wages were payable

6. Please read information contained under point number 3 under ‘General Instructions’ above

7. Write your complete postal address. PIN code in India is equivalent to ZIP code or Area code etc in various countries

8. In case of ‘International Worker’ (that is, a person residing outside India), the payment will be remitted to a valid personal chequing or savings Bank Account only. It should not be a joint account. Please make sure that complete banking details including branch code are indicated.

Declaration below column 8 The employer shall fill the details if member/claimant is applying while still in India.

In case member/claimant is applying from outside India, then EPFO shall obtain these details from employer upon receipt of claim applications.

Declaration to be signed by the employer

(page 2 of the application form) This needs to be signed by the authorised signatory of the establishment in case an ‘International Worker’ (person living

outside of India) this is not required. EPFO will get the needful done from Indian employer

ADVANCED STAMP RECEIPT Persons applying from outside India should not fill this section and they need not affix Revenue Stamp.

~"fi./ Mobile Number

~ ~ <f; ~ ~ (For Office use only)GTCIT ~/Clam I.D .

~~~~.1952EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952

1WlI~20FORM NO-20

>r<fJT~ ~ \iIlo/TT Form to be used: -1. ~/~~ ~ <f; ~ em By the guardian of minor /lunatic member2. ~ ~ <f; ~ / ~ ~ em By a nominee or legal heir of the deceased member.3. ~/~ ~ ~ m '3'i1~I~CIlI~ <f; ~ em ~ '1'fCIl-~ <Ilt ~ ~ ~ c:W <f; ~

By guardian of the minor/lunatic nominee or heir for claiming the Provident Fund accumulation of the minor deceased member

~ : ~ >r<fJTq;T 'i"f m <f m ~ ~ ~ I Note: Read the "Instruction" Carefully before completing the form.~ 1IiT flIlftIrr/Particulars of the member

(1) ~ 1l>T 'W{ ~ 31effl -<1)/ Name of the member (Inblock letters)

(2) fllin/'lfct 1l>T 'W{/ Father's/Husband's Name

(3) ~/~ q;r '{1l'I Cl" l«!T ftR:IlI ~ 3fflm m <i>TI!q;;«If I!UI Name & Address of the Factory/ Establishment inwhich the member was last employed

(4) <IDOT"ffi.<;!rr/ Account No.

(5) ~ ~ <Ilt ~ IDate ofleaving Service

(6) ~ ~ 1l>T ~ / Reason for leaving service

~ ~ <f; ~ "'iI (In case of deceased member)

(7) ~ q\t ~/Date of Death (ddlmm/yyyy)

(8) ~ <f; ~ ~ q\t ~ ~/Marital status of themember on the day ofhislher death

~ $ ftlRvr Particulars of the Claimant~ ~ <f; cmq; ~/~ ~/ ~ <f; ~ em 1f'U \iIlo/TTI

To be filled in by a Major nominee /legal heir/member of the family of the deceased member

(I) <:TciGR <!iT 'W{ ~ arero "'if Name of the claimant (in blockletters)

(2) fllin/'lfct 1l>T 'W{/Father's/ Husband's name

(3) fWT/Gender

(4) ~ ~ q\t ~ <f; ~/ Age(as on Date of death of themember),

(5) ~ ~ ~ q\t ~ q\t ~ q;T)/Marital status (as onthe date of death of member)

(6) ~ ~ <f; ~ ~/Re\ationship with the deceasedmember

~ $~/Signature ofappIicant ~ $ ~/Signature of Employer

Form 20 (www.epfindia.gov.in) Page 1 of4

Deceased Member's CanadianSocial Insurance Number: _______________________________

~/~ ~ cf; ~/lIiRrcf) 6RT 'Iffi ~ ITo be filled by the Guardian/Manager of MinorlLunatic member

m/OR~ ~ cf; ~~ /~ ~(aT) cf; ~ m ~/ ~ ~ (lit)! ~ cf; ~ 6RT 'Iffi \ijJ1/1TT1

Guardian of LunaticlMinor Nominee(s)l Legal Heir (s) !Family member (s) of the deceased member

(1) ~<IiT'WI(vitfcl;~m)Name of the claimant (i.e. Guardian)

(2) flmr/~ <liT'WIFather's/Husband's name

(3) ~/~~cf;~~Relationship with minor/deceased member

~/~ ~ ~/ ~ ~/~ cf; ~ <liTfimur ftRrf; ~ ~ f.!IfEr~ <liTGJCITiIi"RT ~IParticulars of the MinorlLunaticINominee(s)lLegal Heir(s)lSurviving Family Members on whose behalf the Provident Fund Account is claimed

<!S."ff. 'WI IWT =s q'l 'H><I>q! RelationshipS.No Name Gender Date of Relation ~~<f; ~<f;

Birth ~/With ~/ Withdeceased Guardianmember

1

2

3

4

"lift <'IT'l. 'f m or <me ~/ Delete ifnot applicable

(4) ~ <liT'l"f ~ '«IT ~ 3lm't -.{) ~ / ~ / Shri.lSmL.. .

Claimant's Full Postal address (in block letters) ~/~/~/~/ S/o W/o RIo D/o .

................................................... fiR/Pin .

(5) <Tftr~ qft ~ "W!Mode of Remittance

1I'I'~~~tjf.lmrl~Put a tick in the box against the one opted

(cI» <Tftr~ ~ 'R ~ qft "\ij"Jl;/

(a) By Postal Money order at my cost D lJC:" ~ 4 cf; f<tqfuf ~ t«f 'R

To the address given in item No.4

m/OR

«<) ~ ~ q;W ~ ~ ~ m<IT "ff.(~ ~/~)~ ~ ""'" .,<9'1j('if.'t ••• "fl"'f'I "ff erremrm<IT ~ -.);;rr "\ij"Jl;// By account payees cheque/electronic mode sent Direct for credit to myS.B. AlC (Scheduled BankIPO)under intimation to me(attA- ftt; ~"$ "fi1t/~ t<I; *~lIftr·~ 1ft Please attach a copy ofcancelledlblank Cheque)

D~ m<IT "ff./S.B Account no .

tcP <liT'WI/ Name of the Bank .

~/Branch .

anl.1('l>.~. ~ / IFS Code .

~ <liTwr '«IT/ Full Address of the Branch .

~ "$ flmlII'r/Signature of appllcaat f.I$mr" ~/Signature of Employer

Form 20 (www.epfindia.gov.in) Page 2 of4

JI1ITI'TlfJI/CERTIFICATE

\;fliT (fCfj ~ Wof t 1f~ ~ <I>T fcmIm~ t f<I;'lfI'P ~ ~ ~ cffll 'f"i%IT ~ "lift N>rr ITo the best of my knowledge I assure that no Posthomous child will be born to the deceased member1f~~q;l~~tf<l;~fmvT~'l"f~~~~'l"ffim~tlI certify that the particulars given above are true to the best of my knowledge

1f~ CffiIT t f<I;~/~ ~ ~/~/~ ~ ~ ~ ffit/<tt t aft<~ Gm ~ ~ aft<~ f<I;m\jff ffi t mr ufr 'lftrm ~ ~ /~ ~ ~ ~ ~ N \nl ~ ~ mu~*~W<f*t~1

I certify that the minor(s)/ lunatic Sh.lSmt.lKumari... ... ... . .... is living with me and is beingsupported and looked for by myself and the Family Pension Fund benefit received on behalf of minor Iunatic will be spent in hislher best interests &benefits.

1f "EI'Ifur ~ t f<I;~ ~ fil>flt ~ ~/~ if \iI5i f<I;~ ~ ~ aft<~ ~ ~ ~ ~ ~1!1$rr Q?[ ~ ~ ~ ~ WlTcIR <IT lfm ~ ~ "lift 1IR ffi t I

I certify that the minor member has not been employed in any FactorylEstablishment to which the "Act" applies for a continuous periodof not less than 2 months immediately preceding the date of this application

~/ Enclosures ~ ~ ~ ~ 'ffiiIGnt mI!.f ~ ~ <I>T f."mr;fSignature or LeftlRight hand

thumb impression of the claimant

~I DatevU £!PI 'f ~ err ij)JC ~ "Delete if not applicable"

3lftm ~ ffi);r Advance Stamped Receipt$n;r ~ 5(<<)~ ~ if ~ uwfi ~ [To be furnished only in case of5(b) above]

~ ..~ ..~ .... ~ ~:.~~.*.:::::::::::::::::::::::..:..:::::::::::::::'.:'.::::::::::::::::::::::::::::::'.': :..: :::..::.... ..:..:...: :.. ~~ ..~:r:. ~..~..~<~'lft/ ~ I ~~ f.l1tr 'j'fflR ~ if ~ 'I<rn ~ if \jflff ~ ~ ~ ~ IReceived a sum of (*t ('Rupees only) fromRegional Provident Fund Commissioner/Officer-in-charge of sub Regional Office. . ' .by deposit in my SavingBank account towards the settlement of Provident Fund accounts ofShri/Smt... . .

f 1 ffimf~f 1 RevenueStamp

*~ ~ ~ ~ arrg<Rf/~ ~ ~~Gm-.R~~~~~\iIRT~*1be space should be left blank which shall be filled in byRegional Provident Fund Commissioner/Officer in-charge ofS.R.O.

~ <f; trmreR ~ 'll1i I<:lll' mI!.f et; ~ <I>T f.'mRSignature or LeftlRight hand thumb impression of the claimant

~ I~ ~ Gm WII"N?T Certificate by the attesting authority

~ f<I;mumrr t f<I;\3i'R~ ~ mft t Certified that the facts stated above are correct.~ f<I;mumrr t f<I;~ 'lftl ~/~ q;l 1f3l<dt <m V!ROTt aft<~~ mJff ~/~ f."mr;f f<I;mt I Certified that the claimant ShrilSmt.lKumari is known tome and has signed/thumb impressed before me.

~/Date ~m3Rr~~~~~mr~Signature of the employer or any authorised official designation & Seal

Form 20 (www.epfindia.gov.in) Page 3 of4

~ ~ ~ lIliPr tw(For the use of Commissioner's Office)

~ artfWq;/lj',"f 'TfOR 1flIT q;fIf 21-1U 24/2/9 ~ om ~ ~ Tt d "" fRm ~ INc Settled in Part/Full entered in Form 21-N2412/9 (Revised) and withdrawal Register

m.~.TI.SSA

aJ'j.tJ<!SS

~ '$ ~ (Under ~

'TfOR 1fG ~P.I.No. """"".,,""""""""

>Al'ant. / $I>M.O'/Cheque

~~Accounts No.

~ Section """""""""" ~ '$ ~ et; ~ 'Iffi fcI>l.IT Passed for Payment for ~ .. " .. ". """,, ". ",,'" " .. """ .." ...

Accounts Officer~Dated

~ 3lJlWT it WiM it ffi'ii (FOR USE IN CASH SECTION)

~Paid by cheque No. " " "" "" Date " " .. Vide cash booket; mm ~-10 1fG 'W! ~ em f<l;m 1flIT I(Bank) Account No. 3 Date item No.

35.1iIf JSS~REMARKS

TI' 3lT./ ~.3lT/APFCIRPFC

Form 20 (www.epfindia.gov-in) Page 4 of4

Write your Indian Mobile Number (if any) on top of form to get SMS alerts.

EMPLOYEES’ PROVIDENT FUND SCHEME 1952

Form 20

Claim for the withdrawal of Provident Fund Accumulation of minor/lunatic/deceased members

In terms of section 3(5) of the Indian Lunacy Act 1912, "lunatic" means an idiot or a person of

unsound mind

(PLEASE ENSURE THAT YOU ARE USING THE CORRECT APPLICATION FORM AND INSTRUCTIONS

DOWNLOADED FROM YOUR COUNTRY PAGE ON THE ‘INTERNATIONAL WORKERS’ TAB ON

WWW.EPFINDIA.COM. INSTRUCTIONS FOR EACH COUNTRY MAY VARY)

INSTRUCTIONS

WHO CAN APPLY:

1. If the member is a minor, by his guardian;

OR

2. On the death of the member:

a) If a valid nomination subsists: by the nominee(s) of the deceased member if the

nominee(s) is/are minor(s) guardian of the minor(s)

b) If no nomination subsists: by the ‘family’ member(s) of the deceased member duly

supported by a list of surviving family members (as on the date of death of the

member). Include all the necessary particulars, such as: name, relationship with the

deceased member, age, marital status in the case of parents, and whether dependent or

not.

If any family member is a minor, by the guardian of the minor

If both (a) and (b) above are not applicable: by legal heir(s) of the deceased member

duly supported by a legal heir ship certificate.

GENERAL INSTRUCTIONS

1. Claimants who mention their Indian mobile number on the form will get SMS alerts on different

stages of the approval of their claim form. Note: This service is only available to Indian mobile

holders.

The claimants can also visit the epfindia.gov.in website to view the status of their claims

through the link ‘Know Your Claim Status’.

2. All Columns should be filled in clearly in BLOCK LETTERS and there should be no cursive.

www.epfindia.gov.in Page 1 of 3

3. Member’s Account Number: The account number should have the Region Code (two alpha

letters, Office Code (three alpha letters), Code Number (maximum 7 digits), Extension (sub

code, if any, maximum three characters) and Account Number (maximum 7 digits).

The region codes have changed after creation of the multiple regions in some states,

namely Maharashtra, Tamil Nadu, Karnataka, West Bengal, Punjab, Gujarat, Andhra Pradesh,

Uttar Pradesh, Haryana and Delhi. To obtain the correct Region and Office Codes, please visit

Establishment Search facility provided under link for Employees on EPFO’s website

www.epfindia.gov.in or www.epfindia.com

Payment shall be made by directly crediting the Bank Account mentioned by the claimant. The claimant may either indicate his/her Indian Bank Account or the bank account maintained in his/her country. Payment to a foreign bank account is only available in a country with which India has a social security agreement.

Attestation of claim application

In case an ‘International Worker ‘(a worker who is leaving the Indian workforce and is planning

to move abroad):

If theclaimant is applying for a Provident Fund settlement while he/she is still in India, the

application should be submitted through the last employer in India.. The employer will then

forward the claim to concerned Indian RPFC after attestation and completing other formalities.

If the claimant is applying for a Provident Fund settlement from outside of India, the form

should be filled by the applicant and forwarded to International Operations, Service Canada, the

Canadian liaison agency. The liaison agency will in turn forward the application form and any other

necessary information to EPFO for further action.

DOCUMENTS TO BE ATTACHED:

(a) Death certificate, in case the application is by the nominee/surviving family member(s)

or their guardian/legal heirs after the death of the member or certification to that effect

by the liaison agency (if available).

(b) Guardianship certificate issued by a competent court of law, if the application is

preferred by a guardian other than the natural guardian of minor

member/nominee/family member/legal heir.

(c) Copy of the blank/void cheque having the account number and IFS Code or copy of

front page of the bank statement including the complete bank account details and

address of the claimant should be enclosed with claim form.

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(d) Form 5(IF) for claiming the benefits under the Employees’ Deposit Linked Insurance

Scheme, in case:

(i) The member had died while in service,

(ii) The establishment under which the member was working at the time of death

was unexempted under the EDLI Scheme as on his date of death.

(e) Form 10D for claiming the Pension benefits, in case:

(i) The claimant is a family member (Spouse/child under age 25 as on date of death

of member)

(ii) Nominee for Pension, in case the member had no family and had nominated

such nominee for Pension

(iii) Dependent Parents, in case the member had no family at the time of his/her

death and had not nominated any one for a Pension.

(f) Form 10C for withdrawal Benefit, in case the member had died after 58 years of age and

had not completed 10 years of service by 58 years age.

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Canada/India Agreement

Documents and/or information required to support your application [19 for worker] [20 for survivor] for an Indian Provident Fund under the Employees’ Provident

Fund Complete the attached forms:

Information required by the pension authorities in India to process your Indian benefit application under the Employees’ Provident Fund

Originals or certified copies to be submitted:

Your birth certificate if applying as a worker, the birth certificate of the deceased if applying as a survivor

Death certificate if applying as a survivor

Void cheque stamped by your bank containing the following information: o Name and address of the account holder o Details of bank account: branch number, institution number and account number

Guardianship certificate if applying on behalf of a minor as a survivor

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Information required by the pension authorities in India to process

your Indian benefit application under the Employees’ Provident Fund

1. Your full name if applying as a worker (including middle name(s), maiden name and married name, if applicable), or the deceased’s full name if applying as a survivor (including middle name(s), maiden name and married name, if applicable): ________________________________________________________

2. Your Universal Account Number (UAN) or Indian Provident Fund Number if

applying as a worker, or the deceased’s Universal Account Number (UAN) or Indian Provident Fund Number if applying as a survivor: ________________________________________________________ ________________________________________________________

3. Your date of birth if applying as a worker, of the deceased’s date of birth if

applying as a survivor: ________________________________________________________ DD / MM / YYYY

4. Your phone number: ________________________________________________________

2

5. Start and end dates of your employment if applying as a worker, or start and end dates of the deceased’s employment if applying as a survivor, and name and address of your employer if applying as a worker or the deceased’s employer if applying as a survivor:

Start and end dates of employment Name and address of employer

Start date End date

_________________

DD/MM/YYYY

________________

DD/MM/YYYY

___________________________________ ___________________________________ ___________________________________

________________

DD/MM/YYYY

________________

DD/MM/YYYY

___________________________________ ___________________________________ ___________________________________

________________

DD/MM/YYYY

________________

DD/MM/YYYY

___________________________________ ___________________________________ ___________________________________

________________

DD/MM/YYYY

________________

DD/MM/YYYY

___________________________________ ___________________________________ ___________________________________

________________

DD/MM/YYYY

________________

DD/MM/YYYY

___________________________________ ___________________________________ ___________________________________