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Form 2

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rameh29217
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64 views3 pages

Form 2

Uploaded by

rameh29217
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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FORM - 2 (Revised)

NOMINATION AND DECLARATION FORM


FOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS

Declaration and Nomination Form Under the Employees Provident Funds & Employees Pension Schemes

(Paragraph 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 & Paragraph 18 of the Employees Pension Scheme, 1995)

1 Name (In Block Letters) :

2 Father's / Spouse`s Name :

3 Date of Birth :

4 Sex : Male

5 Marital Status :

6 Account Number :

7 Address Permanent :

Temporary :

8 Date of Joining :

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 Birth Total amount if the nominee is minor name &
Nominee(s) relationship with of share of address & relationship of the
the member accumulation guardian who may receive the
in provident amount
fund to be paid
to 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 I
acquire a family hereafter the above nomination should be deemed as cancelled

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

*Strike out whichever is not applicable Signature or thumb impression of the Subscriber

PART - B (EPS)
Para 18

I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension
in the event of my premature death in service.

S.No Name of the Family Members Address Age Relationship

"Certified that I have no family as defined in para 2 (vii) of the Employee’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on 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 the Nominee Date of Birth Relationship with the member

Date : Signature / Thumb impression of the subscriber


CERTIFICATE BY EMPLOYER

NITHIN KUMAR GUNDELLI

Date :
Signature of the employer or other authorised officer of the establishment

Name & Address of the Factory/ Establishment

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