FORM 20

Mahangar Telephone Nigam Limited Employees Provident Fund Trust

EMPLOYEES PROVIDENT FUNDS SCHEME, 52

Form to be used : [1] By the guardian of the minor/lunatic member

OR
[2] by nominee or legal heir of the deceased member
OR
[3] by the guardian of the minor/lunatic nominee or heir for
claiming the provident fund accumulation of minor /
deceased member
----------------------------------------------------------------------------------------------------------------------------------------------------------

PARTICULARS OF THE MEMBER

1. a. Name of the member[ in Block letter] :

b Fathers / husband’s name :

c Name and Address of the Factory/ :

Establishment in which the member
was last employed

d Account number :

e Date of leaving service :

f Reason for leaving service :

[IN CASE OF DECEASED MEMBER]

g Date of death of member :

h Marital status of 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. Fathers / husband's name :

c. Sex :

d. Age(as on the date of death of the member) :

e. Marital status of member [as on the day of death of :

member] (Whether married Unmarried,
widow,or widower)

f. Relationship with the deceased member :

3. To be filled in by the Guardian/Manager of the Lunatic Member/Lunatic/Minor [Nominee[s]]
Legal Heirs[s] of the deceased Member Family Member[s]

a. Name of the Claimant { i.e. Guardian}

b. Fathers/Husband's Name

c. Relationship with the member/deceased member

3A. PARTICULARS OF THE MINOR/LUNATIC NOMINEE(S) LEGAL HEIR(S) FAMILY MEMBER(S) ON

WHOSE BEHALF THE PROVIDENT FUND AMOUNT IS CLAIMED.

------------------------------------------------------------------------------------------------------------------------------------------------------
S.No Name Sex Religion Relationship
|
with the deceased member | with the
| guardian
-----------------------------------------------------------------------------------------------------------------------------------------------------------

(1)

(2)

(3)

(4)
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Delete, if not applicable
---------------------------------------------------------------------------------------------------------------------------------------------------------------

4 Claimant’s full postal address : Shri/Smt ………………………………………………………….

(in Block Letters)
S/o, W/o, H/o, D/o……………………………………………….

……………………….……………………………………………

…………………………………………………………………….

PIN:
----------------------------------------------------------------------------------------------------------------------------------------------------------------
5. Mode of remittance:

By account payee cheque or through ECS sent direct for credit to my S.B. A/C under intimation to me

S.B. Account No............................................................... MICR Code………………………………………..

Name & Address of the Bank/Branch…………………………………………………………………………………………..

--------------------------------------------------------------------------------------------------------------------------------------------------------------

Certificate:

To the best of my knowledge no posthumous child will be born to 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 benefits.
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 2 months immediately preceding the date of this application.

Signature or Left/Right hand

thumb impression of the claimant
Date:
 ADVANCE STAMPED RECEIPT
(To be furnished only in case of 5 above)

Received a sum of Rs. .........................(Rupees .. from

MTNL, Employees Provident Fund Trust by deposit in my Savings Bank account towards the settlement of
Provident Fund Account of Shri/Smt./Km._____________________________

Affix 1/- Rupee

Revenue
Stamp

Signature or Left / Right hand thumb impression of the claimant

 INSTRUCTIONS
 All the columns in the form should be filled in completely in ink without any overwriting.

 By whom the claim application should be preferred?

1. If the member is minor, by his guardian, OR

2. On death of the member:-

(a) If a valid nomination subsits: by the nominee (s) (if the nominee (s) is/are minor (s),
guardian of the minor (s).

(b) If no nomination subsits : by the ‘family’ member’s (family includes posthumous child
also, if any), except major sons and married daughters whose husbands are alive of
the deceased member duly supported by a list of surviving family members (as on
the date of death of the member). If any family member is a minor by the guardian
of the minor.

(c) If both (a) and (b) are not applicable:- by Legal heir (s) duly supported by a
legalheirship certificate from the appropriate State (normally Revenue) authorities.

 The following documents should be enclosed in support of the claim:

(1) A copy of Death Notification/Struck-off orders.

(2) A copy of L P C (Last Pay Certificate).
(3) A copy of Presidential Orders / proof of date of joining in MTNL.
(4) A copy of first page of Service Book.
(5) List of surviving family members as mentioned 2(b) above. Form is available on site.
(6) Legalheirship certificate as mentioned 3 (c) above.
(7) The literate member should sign the application form. Illiterate male member should
affix his left hand thumb or illiterate female member should affix her right hand thumb
impression and the fact should be clearly recorded below the thumb impression.

 If you feel any difficulty in filling up the form, you may contact over phone no. 23218644,
23218735.