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Form 2 New

This document is a nomination and declaration form for the Employee’s Provident Funds and Employee’s Pension Scheme, intended for both unexempted and exempted establishments. It requires personal details of the subscriber, nomination of beneficiaries for provident fund and pension, and certification by the employer. The form includes sections for providing information about nominees and family members eligible for pensions in the event of the subscriber's death.

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Priyadarshini S
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64 views2 pages

Form 2 New

This document is a nomination and declaration form for the Employee’s Provident Funds and Employee’s Pension Scheme, intended for both unexempted and exempted establishments. It requires personal details of the subscriber, nomination of beneficiaries for provident fund and pension, and certification by the employer. The form includes sections for providing information about nominees and family members eligible for pensions in the event of the subscriber's death.

Uploaded by

Priyadarshini S
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 UNEXEMPTED /EXEMPTED ESTABLISHMENTS


Declaration and Nomination Form under the Employee’s Provident Funds and Employee’s pension Scheme

(Paragraphs 33 & 61 (1) of the Employees’ Provident Fund Scheme, 1952 and Paragraph 18 of the Employee’s Pension scheme, 1995)
1. Name (in Block letters) :

2. Father ‘s/Husband’s Name :

3. Date of Birth :

4. Sex :

5. Marital Status :

6. Account No. :

7. Address : Permanent :

Temporary :

8. Date of Joining :

PART – A (EPF)
I hereby nominate the person (s)/ cancel the nomination made by the previously and nominate the person (s) mentioned below to
receive the amount standing to my credit in the Employee’s Provident Fund, in the event of my death

Name of nominee / Address Nominee’s relation- Date of Birth Total amount of If the nominee is minor,
nominees ship with the share of name &relationship&
member accumulations in address of the guardian who
provident Fund to be may receive the amount
paid to each nominee during the minority of
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 dependent upon me.

Signature or thumb impression of the subscriber

• Strike out whichever is not applicable.


Part B (EPS) (Para 19)
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 death.
S. No. Name & Address of Date of Birth Relationship with member
The family member
Name Address

1 2 3 4 5

1
2.
3.
4.
5.
6.

**Certified that I have no family as defined in para2 (vii) of Employee’s 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 widow pension (admissible under para 16.2(a) (i) and (ii) in the event of
my death without leaving any eligible family member for receiving Pension.

Name and Address of the Nominee Date of Birth Relationship with the member
1 2 3

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 and got confirmed by him /her.

Place: ........................................ Signaturethe employer or other of


Authorised office of the Establishment

Designation.....................……………

Date: Name &Address of the factory /


Establishment or rubber stamp thereof

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