DOJ: FORM 2 (REVISED) EMP ID

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 (1) of the Employees’ Provident Fund Scheme, 1952 and Paragraph 18
of the Employees’ Pension Scheme, 1995).

1. Name(In Block
Letter) FATHER'S/HUSBAND'S
NAME SURNAME
NAME
2. Date Of Birth 3. Account No.
5.Marital Status:
4. Sex : Male / Female
Married/ Unmarried/
:
Widow/Widower
6. Permanent
Address:
7.Temporary Address:

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.

If the nominee is
Total amount minor, name
Nominee’s or Share of relationship &
Name & Date
relationship accumulations address of the
Address of the of
with the in P.F. to be guardian who may
Nominee (s) Birth
member paid to each receive the amount
nominee during the minority of
nominee
1 2 3 4 5

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 cancel.

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

* strike out which 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 death.

Name and Address

Relationship with
Sr. No. of the Family Date of Birth
member
member

.. Certified that I have no family, as defined para 2 (vii) of the Employees’ 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 [ admissable under
para 16 (2) (a) & (ii) in the event of my death without leaving any eligible family member for receiving
pension.

Name & Address of Relationship with the

Sr. NO Date of Birth
the Nominee member
(1) (2) (3) (4)

Date :

.. Strike out which 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 /Miss employed in my establishment after he / she has read the entries the entries have
been read over to him / her by me and got confirmed
by him /her.

Name & Address of the Factory / Establishment Signature of the employer or other authorised
Or Rubber Stamp thereof officer of the establishment
Place:
Date:
 FORM 'F'
[See sub-rule (1) of rule 6]
Nomination

To
<>
[Give here name or description of the establishment with full address]

I. Shri/Shrimati/Kumari whose particulars are given

in the statement below, [Name in full here]

hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also
the gratuity standing to my credit in the event of my death before that amount has become payable, or
having become payable has not been paid and direct that the said amount of gratuity shall be paid in
proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within
the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of section (2)
of the said Act.
4. (a) My father/mother/parents is/are not dependant on me.
(b) my husband's father/mother/parents is/are not dependant on my husband.
5. I have excluded my husband from my family by a notice dated the ………………… to the
Controlling Authority in terms of the proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Proportion by
Name in full with full address Relationship which
Sr. Age of
of with the gratuity will
No. nominee
nominee(s) the employee be
shared

Statement

1 Name of employee in full

2 Sex.
3 Religion.
4 Whether unmarried/married/widow/widower.
5 Department/Branch/Section where employed.
6 Post held with Ticket or Serial No., if any.
7 Date of appointment.
8 Permanent address.

Sub- Post
Village Thana
division Office
District State

Date
Place Signature/Thumb impression of the
employee
 Declaration by witnesses

Nomination signed/thumb impressed before me.

Name in full and full address of witnesses Signature of witnesses

1. 1.

2. 2.

Place:

Date:

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this
establishment.

Employer's Reference No., if any.

Signature of the employer/

officer authorized

Designation

Name and address of the establishment or

Date:
rubber stamp thereof.

Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the
employer.

Date Signature of the employee

 New Form No.11- Declaration Form
(To be retained by the employer for future
reference)
EMPLOYEES PROVIDENT FUND ORGANIZATION
Employees provident funds scheme, 1952 (paragraph 34 & 57) &
Employees pension scheme 1995 (paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952
end /of EPS1995 is applicable)
1 Name of the member
Father’s Name ( ) Spouse’s Name ( )
2
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY)
4 Gender: ( male / Female /Transgender )
5 Marital Status (married /Unmarried /widow/divorcee)
(a)Email ID:
6
(b)Mobile No:
Whether earlier a member of Employees ‘provident Fund
7
Scheme 1952
Whether earlier a member of Employees ‘Pension Scheme
8
,1995
Previous employement detail [is yes to 7 And/Or 8 above]

a) Universal Account Number(UAN)

b) Previous PF Acount Number
9
c) Date of exit from previous employment (DD/MM/YYY)
d) Scheme Certificate No (if Issued )
e) Pension Payment Order (PPO)No (if Issued)
a) International Worker:
b) If Yes , State Country Of Origin (India /Name of Other
10 Country)
Passport No
Validity Of Passport (DD/MM/YYY) to(DD/MM/YYY
KYC Details: (attach Self attested copies of following KYCs)
**

11 a) Bank Account No .& IFS code /

b) AADHAR Number (12 Digit)
c) Permanent Account Number (PAN),If available
UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge
2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable if applicable, from the previous PF
account as declared above to the present P.F Account(The Transfer Would be possible only if the
identified KYC details approved by previous employer has been verified by present employer
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date:
Place: Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member Mr./Ms./Mrs has joined on .and has been allotted PF
Number……………………………….
B) In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995

(Post allotment of UAN ) The UAN Allotted for the member is

Please tick the Appropriate Option:
The KYC details of the above member in the UAN database

Have not been uploaded

Have been uploaded but not approved
Have been uploaded and approved with DSC
C) In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:

The above PF account number /UAN of the member as mentioned in (a) above has been
tagged with his /her UAN/previous member ID as declared by member
Please Tick the Appropriate Option

The KYC details of the above member in the UAN database have been approved with
digital signature Certificate and transfer request has been generated on portal.
As the DSC of establishment are not registered With EPFO the member has been
informed to file physical claim (Form13) for transfer of funds from his previous
establishment.
Signature of Employer With seal of
Date:
Establishment