FORM – 2 (revised)

EMPLOYEES’ PROVIDENT FUND ORGANISATION

NOMINATION AND DECLARATION FORM

FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme.
(Paragraph 33 and 61 of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’
Pension Scheme, 1995)

1 Name (in Block Letters) SHWETA SINGH 7 Permanent Address

Emp No:_______231___
2 Father’s/Husband’s Name . K SINGH NO.45, 7TH MAIN, K LAYOUT,
(in case of married Women) MADIWALA, BANGALORE-
560078
3 Date of Birth DD/MM/YY
Temporary Address
4 Sex Female
NO.45, 7TH MAIN, K LAYOUT,
5 Marital Status Married MADIWALA, BANGALORE-
This needs to be 560078
6 left empty
Account No KN / 25530 /

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 & Address of Nominee’s Date of Total amount or If the nominee is a minor,
Nominee/s Relationship Birth share of name relationship and
with the accumulation in address of the guardian
Member Provident Fund to who may receive the
Immediate be paid to each amount during the
family only- nominee minority of nominee
No brother 1 2 3 4 5
and sister
P singh Father 5/11/1956 50%
TH
NO.45, 7 MAIN, K LAYOUT,
MADIWALA, BANGALORE- 560078

M Singh Mother 6/12/1958 50%

NO.45, 7TH MAIN, K LAYOUT,
MADIWALA, BANGALORE- 560078

1. *Certified that I have no family as defined in para 2(g) of the Employees’ 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 dependent upon me.

*Strike out whichever is not applicable. Signature/or thumb impression of the subscriber
FOR OFFICE USE ONLY

Dt. of Joining E.P.F / /20 . . ENTRIES VERIFIED

Past Service ______________ Year

D.A S.S A.A.O
Date of Joining EPS / /20
 PART – B (EPS) Para 18

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

SI. No. Name of the family Address Date of Birth Relationship with member
member
1 2 3 4 5
Immediate NO.45, 7TH MAIN, K LAYOUT,
1. P singh 5/11/1956 Father
family only- MADIWALA, BANGALORE-
No brother 560078

and sister M Singh NO.45, 7TH MAIN, K LAYOUT,

6/12/1958 Mother
2. MADIWALA, BANGALORE-
560078

3.

4.

**Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and
should I acquire a family hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly pension (admissible under para 16 (2) (g) (i)
& (ii) 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

Fill in the details as mentioned in the

above table

Date:

*Strike out whichever is not applicable. Signature /or thumb impression of the subscriber.

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.

Signature of the Employer or other authorised Officers of the Establishment

for Actiance India Private. Ltd

Designation
Authorised Signatory

Date:……………. Name & Address of the Factory/Establishment or Rubber Stamp thereof.

Actiance India Private. Ltd

Salarpuria Cambridge, Second Floor,
9,Cambridge Road, Ulsoor, Bangalore - 560 008.