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PF Nomination Form

This document is a nomination and declaration form for the Employee's Provident Fund and Employee's Pension Scheme. It allows an employee to [1] nominate individuals to receive their provident fund savings in the event of death and [2] provide details of family members eligible for pension benefits. The form collects information such as nominee names and relationships, family member names and ages. It must be signed by the employee and certified by an authorized employer representative.

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HR SPEEVO INDUSTRIES LLP
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551 views2 pages

PF Nomination Form

This document is a nomination and declaration form for the Employee's Provident Fund and Employee's Pension Scheme. It allows an employee to [1] nominate individuals to receive their provident fund savings in the event of death and [2] provide details of family members eligible for pension benefits. The form collects information such as nominee names and relationships, family member names and ages. It must be signed by the employee and certified by an authorized employer representative.

Uploaded by

HR SPEEVO INDUSTRIES LLP
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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NOMINATION AND DECLARATION FORM FORM-2 (REVISED)

FOR UNEXEMPTED/ EXEMPTED ESTABLISHMENTS

Declaration and Nomination form under the Employee's Provident Funds & Employee's Pension Scheme
( Paragraph 33 & 61 (1) of the Employees provident Fund Scheme 1952 & Paragraph 18 of the Employees
Pension Scheme; 1995 )

1. Name (in Block Letters) 6. Account No.

2. Father's/Husband's Name 7. Address

3. Date of Birth

4. Sex Temporary

5. Marital Status

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 Address Nominee's Date of Total amt. or If the Nominee is a minor name &
nominee/nominee's relationship Birth share of relationship & address of the
with the accumlations in guardian who may receive the
member Provident Fund amount during the minority of
to be paid to nominee
each nominee

1 2 3 4 5 6

1. * Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme 1952
and should acquire a family hereafter the above nomination should be deemed as cancelled.

2. * Certified that my father/ mother is/are dependent upon me.

Signature or thumb Impression


of the subscriber
PART B (EPS)
(Para 18)

I here by furnish below particulars of the members of my family who would be eligible to receive
widow/ children Pension in the event of my death.

S. No. Name & Address of the family Address Date of Relationship with member
member Birth / Age

** Certified that I have no family, as defined in para 2 ( vii ) of Employee's Pension Scheme, 1995
and should I acquire a family hereafter I shall furnish particulars theron 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 Date of Birth / Relationship


Age
the nominee with the
member

Date Signature or thumb impression


of the subscriber

** Strike out whichever is not applicable

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed /thumb impressed before
me by Shri/Smt/Kum . employed in my establishment after he/she has
read the entries/entries have been read over to him/ her by me and got confirmed by him/her.
for Name of Company

AUTHORISED SIGNATORY
Place : Signature of the Employer or other
authorised officers of the establishment

Dated :
Designation :

Name & address of the Factory/Establishment


or Rubber stamp thereof

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